8 replies to this topic

[Hassan265]

Hi, 

 

Anyone there who has had experience filling in a root cause analysis form on the following customer complaints?

 

• Improper date code printed on the product 

[Elleflores619]

Hi you will have to do your investigation once you have conducted an investigation that will determine your root cause. For example if a qa technician did not do a pre operational ink jet inspection along with the production supervisor that is your root cause. Once you have your root cause you will of course have to create a preventative measure and corrective action plan. Hope this helped you.

[DLH]

We have had a similar situation happen in our facility.  We were using a price sticker gun to apply the date code stickers and partway through the day one digit got switched.  

We already had in place a check at the start of production to ensure the date code was set correctly. 

With this type of system there was not much we could do to lock the gun to prevent this from happening so we implemented a midshift and end of shift check on the date code.  

If you are using an inkjet type printer and you did not have to change the code through out the day then you may simply need to implement a check at the start of the day to ensure the code is correct.   

[Madam A. D-tor]

Dear Hasson 256,

 

To find the root cause it always helped me to ask 5 times "why?".

 

Example:

Deviation:                    improper date printing

why 1:                         why was the date printed improper?

answer (example):       because the printer was running out of ink

why 2:                         why was the printer running out of ink?

answer:                       because it was not filled on time

why 3:                        why  was it not filled on time?

answer:                       because the operator did not check the ink level on time

why 4:                         why did the operator not check the ink level on time?

answer:                       because he had no time/ forgot it.

why 5:                         why did the operator had no time/forgot it?

answer:                       because he was busy solving an equipment failure of another machine.

 

sometimes you need more "why?"s. Sometimes you find the solution sooner. If a question has more answers e.g. printer run out of ink and the finished product check was not conducted, than follow both answers again with why-questions.

 

Root causes are mostly related to: providing resources, providing training, maintenance, lack of time/ too busy staff, uninterested or unwilling staff, design of equipment, design/flow/layout of buildings.

[afcbno1fan]

To add to that, never be afraid to write 'human error' as the root cause. In my experience it tends to be the biggest driver of non-conformance

[GMO]

To add to that, never be afraid to write 'human error' as the root cause. In my experience it tends to be the biggest driver of non-conformance

 

Yes but... why?!  Human error doesn't come out of a void.  It happens for a reason.  E.g. tiredness, lack of motivation to do the task (e.g. their supervisor doesn't see it as important), no time to do the task, lack of resources, equipment doesn't work properly so they're doing a "work around".

 

Another useful tool is a "fish bone" diagram as that encourages you to think about different categories, e.g. materials, environment, people etc. which may have contributed to the problem.  With each issue you can then drill down further using "5 whys" as well. 
 

https://en.wikipedia...shikawa_diagram

Personally I think "5 whys" on it's own can be good and can be bad depending on who is using it and their experience.  It is very easy to direct yourself down the route you "expect" to get to rather than consider all options.  It also can result in only one root cause whereas "the Swiss cheese effect" which is often considered in accidents suggests it's often multiple failures which result in the incident.  So for example, while your coder may have been set up wrong because someone was tired, it may also have been set up wrong because it was temperamental on "pre set" mode.  The mistake may not have been noticed because the person doing label checks did so in a darkly lit area with no coding calendar to compare with.  The person running the line may have been insufficiently trained, etc, etc.  It tends to be all these things coming together that results in an incident not just the one failure so IMO, I always try and look at every reason and also why it wasn't detected as you want your best chance to avoid recurrence. 

 

[Madam A. D-tor]

To add to that, never be afraid to write 'human error' as the root cause. In my experience it tends to be the biggest driver of non-conformance

 

and beyond that "human errors" are themselves mostly caused by improper resource management. Causes of human errors can be: too less training, no time for instructions, insufficient (not understandable) instructions, to busy/stress, doing to much things at the same time, etc. These can all be solved by management team by providing sufficient resources. That is why root cause analyses are in the management chapters of BRC and ISO 9001.

[afcbno1fan]

^{To add to your first post I could ask why was the operator too busy solving a problem with another machine}

^{A: There wasn't enough resource to repair both at the same time}

^Why?

 

^{You can drill down and down. I have never been challenged using human error as the root cause as long as that was the root cause}

 

^{I am all too familiar with Ishikawa having read quality systems at Uni and helped facilitate the lean program at Kerry Foods}

 

^{Thanks for your reply as it is something else to consider}

[GMO]

 

 

^{You can drill down and down. I have never been challenged using human error as the root cause as long as that was the root cause}

 

 

 

 

If I were your auditor I would challenge you.  I would say "human error" is almost never the root cause.  There is always the "why" which goes behind it.  There is a really nice article on human error I've just found which puts it really well.  It's about IT but the lessons are the same.
 

I also have another example for you.  In a factory I used to work in, I had a hygiene team.  One member of the team had been promoted years before to Team Leader but we had repeated problems with hygiene on the shift.  Auditors would ask her if she'd checked her team's work, she'd confirm she had for the auditor to find big bits of food debris in obvious places.  We thought the root cause was understanding, so we trained her.  We thought the root cause might have been visibility so she had her eyes checked and we gave her torches to be able to see the debris better.  We thought it might be due to lack of knowledge of how to organise her team, we gave her advice.  In the end we had to go down the performance capability route.  She was given very clear objectives in how to improve but didn't achieve a single one.  In the end we demoted her to a basic cleaner and she was still unable to do the task so we dismissed her. 

Was that human error?  No.  The root cause was around her appointment and promotion in the first place.  When she was appointed to that role, getting the lines up and running at the right time and length of service and commitment was seen as the most important things not whether she was capable of cleaning the machines to a good level and organising her team to do the same.  As a management team on recruiting her we valued the wrong skills.  We also then continued to fail to take action on poor performance for far too long.  It was not human error it was bad management skills.

 

Give an example of "human error" being root cause and see if we can think of any other root causes which could have been behind it.