So what we've done now with the process flow is really just understanding what I've, when it's happening, and how it's happening. All we haven't really identified properly is any root causes. So that's really what we're going to look at now. We're going to ask the question, why is it happening? And we're going to do some root cause analysis. And there's two very common tools in lean that you might use for this one's called Five why or five whys.

And the other is called the fishbone diagram, sometimes called the Ishikawa diagram, named after the gentleman who came up with it for Toyota. So the five why's tool we will look at that in more detail in a moment. But essentially, what it boils down to is just asking why this has happened. Well, we get an answer. We say, Well, why did that happen? So why did that cause that?

Why did that? Why did that happen? So you ask why? Five times. So if you have children, you'll be used to Why because it's what children tend to do. And, but it's really just a way of trying to get to the bottom, the root cause of why something has happened.

And the idea is if you ask that question five times, then you're more likely to get to the bottom of it, or at least at a level, that you've, you've got some reasonable likelihood that you'll get to the nub of the problem and stop it from happening again. There are some dangers with five what I one thing I would say is make sure that the person you're doing it with knows that you're trying to use a tool called Five, why? And make sure that they are part of it. If you don't tell them and you just keep saying why five times, you might find that you have quite a lot of, let's say aggression towards you, because they might just think you're trying to be awkward and funny with them. So if you make sure that they know that you're doing a five why it's not about trying to find blame, it's just about trying to understand what's happening, then that's much better.

The other root cause analysis tool is called the fishbone diagram or Ishikawa diagram as I've mentioned. And I'll just show you on this illustration how that works. You basically start with the effect that you're getting. So you start at the end, if you like, what's happening now? What's the current effect? And then what you do is you trace back, what could be causing that effect.

Now, there are four standard labels that many people use, but you can actually use whatever labels you want. We've got equipment on there. So that's all of our labels. So what is it about our equipment that's causing our problem? People is another one of those standard labels. So is there anything around the way that people do what they do or their skills or how they do it that could be creating the problem?

Or at least contributing to it? What about the materials that we use? Could they be contributing to the effect that we're getting that we don't necessarily want? What about our methods? Are they contributing to the effect that we're getting? So what you then do is you just use As little lines to write on what you think might be contributing to the effect.

So this is a great tool to use with a team. So if you get your team together, start to talk to them about right, this is what's happening, what could be causing it? And what could be causing it from the point of view of our equipments, what could be causing it from their point of people, what could be contributing from the point of view of our materials, or our methods, and just try to get as much as possible to identify what the root causes. So what we're going to do now is just have a look at a very simple example. While we might want to do some current state analysis, so we're going to use fishbone diagram we're going to use five why's we're going to have some sensible questions. And so we're going to use this as a bit of an exercise.

So the reason why is where we keep missing our production targets. That's the thing that prompted us to want to do something about this do any improvement projects on this So, following the process, we need to ask some simple questions. The first question we need to ask is what do we mean by missing production targets? How are we measuring that? Do we mean that we're missing them every day? Are we missing them every week?

Is it that we are producing it, but we've got too much waste? Which means we're having to do it again? Or is it that we're just not producing enough or not in time? So we just need to understand what we mean by those production targets. Specifically, what is the problem? How are we measuring that?

Both in terms of what methods are we using to capture that data? And what is the data itself? How often is it happening? When does it happen? Is it on a particular shift? Or maybe it's at the weekend, or maybe it's Christmas or New Year or when we're really busy or not always busy?

So we just need to understand when those things are happening, and what sort of issues they are Cause is it particular products or services that are the real problem, maybe everything else is okay, just a half a dozen of our products are causing the problem. So which ones are they? So going to do a fishbone diagram now, where we can have a look at what might be causing the effect that we don't want, which is this, we keep missing out production targets. We've defined it better now, whatever that definition is, and we can put that effect in that effect box. I strongly recommend you get your team to work with you on this or at least at to work with you on this is pretty soul destroying to do it on your own. And you need the wisdom of the group really, to help you understand what's happening.

So then you populate these areas here. So we ask our question, what is it about our equipment that's contributing to the effect that we don't want? So is there something about our equipment or machinery that's contributing to the fact that we keep missing out prediction targets Maybe it's because we had five machine breakdowns per week. Maybe it's because the machines are really designed for the product that we're using them for. That's often the case in manufacturing, or indeed in services where we're kind of making something do and maybe we've got some long changeovers. So change overs in manufacturing, but it applies to other things, too, is the time it takes for you to stop making one thing to change your equipment or machinery and set yourself up to do the next thing.

So it's that kind of change over time where you're not producing anything because your machine is being ready for the next thing. So maybe that's what's happening. What is it about our methods that could be contributing to the effect where we keep missing out production targets? Are we double handling materials? Is it about the way that we handle our materials? Change overs this time is it that they're done straight after break, so we organize our changeovers.

When people are coming back after break, why can we do change overs when people were on break, for instance. So those sorts of things could be obvious, but might be causing part of the problem. The line isn't balanced. And that means, again, in manufacturing, it could be that some people are really busy, because they've got lots of stuff coming to them. But other people on the production line are maybe not very busy. So that means that the line is unbalanced.

Okay, that could be contributing to the issue. What is it about our materials that could be contributing to the effect? So maybe we because we've switched materials, we've decided to go with a different type of material. Maybe that's meaning that we have to do increased quality checks, which holds everything up. We get we're getting more rejects. So we're having to throw more things away more rework and so on.

We might have a new grade of material that in itself is is fine. But it just keeps getting stuck in one of the machines. So it could be that that's creating the problem. What is it, but what could it be about are people that could be contributing to the effect. So maybe they don't know how to do a changeover properly, they don't have the training operators are not recording rates, which means that we're not able to take action sooner. So we only get to know about the problem Two days later, whereas if we'd had rates being recorded regularly, we could perhaps take some action.

Maybe there's some confusion over roles that people don't quite know whether they should be doing this or that. So we get this confusion that could be causing some of the problem that we are seeing. So basically, you're just filling in those elements of the fishbone diagram. And as you can see, you've got lots to choose from there. So what you could do is if you wanted to drill down further into that, you could take one of those and put that in the effects box, and then you could start it So in theory, you can kind of keep going down and down and down and get deeper and deeper into the root cause. So that's one way you could use that.

What I'm going to do is give you an example of using a five y tool after a fishbone. So let's say you've done the fishbone diagram, you've got your team to work on that. And one of the main things that's been identified is that operators are not recording rates, because they're not recording rates, the problem is being spotted too late, and you're not able to do something about it earlier. So it could be any of those, but we're just going to focus on that one, just because we want to look at a five wide. So what we're going to do is we're going to take that particular element, which is operators not recording rates, with identify that that is creating some problems, and we're going to do a five why exercise on that. So why are operators not recording rights?

So we'd have to ask that question. Now finding out the answer to that is obviously important. Let's imagine we go and talk to operators, we go and talk to managers and so on. And we start to get some answers to those questions. Honestly, they just don't see it as important. They're really busy.

And they're getting on with the important stuff, which is getting the product out the door. They just don't see that that's important. It takes them too long to fill it in. So, a second question you might ask there is, well, why don't they see it as important? Again, you need to ask that question. You need to do so in such a way, though, that you don't just create a defensive mechanism coming back to who's really interested.

What is it about that that just doesn't seem to grab the person's attention as being something important? Well, honestly, they just don't understand the reasons for doing it to the operators. It just feels like another job they've got to do, which is taking them away from their core activity. So why don't they understand the reasons why don't they see it as important Be the next question. Well, it could be that we haven't really involve them in projects in the past, when we've introduced this system of recording information, so they don't really know why they're doing it. They weren't involved in it.

They just think it's another thing that the manager is trying to get them to do. So they don't understand the reasons because we've not involved them in why we're doing it. Why have we not evolved them then would be a good question to ask. Well, maybe it's because traditionally, we only involve continuous improvement managers or other managers in projects. So they're the ones that introduce these new ideas. They're the ones that design the form.

They're asking people to fill them in. They don't really have any stake in that or any buy in at all. So why have we only involved the managers? Well, that's really part of our process. When we're doing improvement process, we don't have a plan for involving the team. We've never done that.

It's not part of the project management process. So really in a way with identity Something that we probably wouldn't have thought about as being a problem. But it's really around the way that we engage the workforce, in how we do our measures, how we identify what's going on the factory. And that's the reason why people are just not fitting that thing in. So identify something a bit surprising, a bit unusual through that five why's process. So my recommendation is do a fishbone diagram First, identify some areas that you now want to do some five, why exercises and just pick those that gives you the best of both worlds really, you've got this high level, lots of things could be causing the problem.

Then let's drill down into some using a five Why's the other thing just to bear in mind with with five Why is that? Because it's essentially a case study approach. You can take that particular case study as being representative of lots of others. That might not be the case. Be there on this particular case that you're looking at the root cause was something different to a different case. So my recommendation there is to do more than one, five, why?

So do a few finds more than one case to work on? do five why's on each of them? Then if you come up with the same thing every time, that's telling you something, so five, why a useful tool, but do it in conjunction with your fishbone diagram, and don't just do one? So where are we up to our simple improvement process? Well, we've had a look at why you might want to change something. And we've really looked at that from the perspective of lean.

So Tim woods, the different ways of describing waste. We then looked at the current state analysis, and we've done a couple of things on that. Firstly, we've identified what's actually happening by using a process flow. So do a flow diagram, or do a process flow diagram where you can see what's currently has Do it on paper. Again, get people involved so you can understand what's currently the situation. Then do a root cause analysis where you're looking at why things are happening, which is where you would bring in a fishbone diagram and the five why's to use root cause analysis to identify the reasons for it.