Root Cause Analysis for SQF Audit Non-Conformances

We just passed our first SQF audit and are now working on completing CARs. I have two specific questions:

1. One of our NCs was due to 11.1.2.8, "The drop ceilings in the offices are not monitored for pest activity". I'm using the 5-Why approach, and one of my "Whys" and Preventative Actions was going to be:

Why:

"The internal auditor who performed the audit of FSMS55 section 11.1.2.8 had an incorrect understanding of what a "drop ceiling" was which resulted in no finding during the Internal Audit"

PA:

"Add the definition of a "Drop Ceiling" to section 11.1.2.8 of the Internal Audit Document"

Does this seem like an appropriate RCA and PA? My worry is having an RCA resulting in some type of "human error". Not sure if I'm overthinking. 

NOTE: After our audit, the company we hired to conduct our audit sent us a document on conducting RCAs. In this document, they do not state any limitations on the outcome of a RCA

2. I have not been able to come up with 5-Whys for a few of the Non-Conformances. Is this an issue? As I noted above, the document they sent me outlining how to complete the RCA/PA, they noted the "Five Why's Analysis", though didn't say anything about requiring 5 total "whys".

So in conclusion... Help! 

On your first why you can put as PA: The internal auditor was not able to capture on the audit report the drop ceiling as possible pest activity. Then maybe you could sight lack of training as RCA or inadequate training.

NorCalNate- I agree with the post above. I'd go down the training route. Typically if you have done the 5 Why's and your last why leads you to a specific person or specific role go back up and ask why again. It cannot fall on one person as these programs are team efforts, I'd make it a training failure and move on. I have gotten to root causes in 3 why's so do not think you have to always have 5. Their thinking is that within 5 questions you should have an answer. Passing your first audit is a great feeling. Remember you are more than likely going to deal with the same audior and technical review team next year, don't be afraid to ask them questions that is why you pay them for the serivce. 

Agree that training may be your best route for #1.  It is completely fine if you cannot come up with 5 why's for the others, there is nothing stating what you need to use to come up with your root cause for the non-conformances.  Keep it simple and make sure you are listing the true root cause and try not to go down any rabbit holes on them.

I have to ask, are you sure about the drop ceiling?  Are you saying there is absolutely no void above the ceiling?

It's probably going to go over like a bag of hammers if you state in your CA that the auditor didn't understand the definition (even if that's true) 

I have to ask, are you sure about the drop ceiling?  Are you saying there is absolutely no void above the ceiling?
 
It's probably going to go over like a bag of hammers if you state in your CA that the auditor didn't understand the definition (even if that's true)

We have been certified for more than 5 years and we had a NC for the same reason; as a PA we talked and agreed with our Pest Control Company to include an inspection at least monthly for the drop ceiling. I do not remember how we replied for our RCA, but that was the PA at the end. 

I hope it helps you. 

 

Why:

"The internal auditor who performed the audit of FSMS55 section 11.1.2.8 had an incorrect understanding of what a "drop ceiling" was which resulted in no finding during the Internal Audit"

 

 

Was this the first WHY you came to?   There were no other contributing factors?  The 5 whys system will only work if you come to it with a theory only,  this reads as if you came into it with a conclusion 

I have to ask, are you sure about the drop ceiling?  Are you saying there is absolutely no void above the ceiling?

 

It's probably going to go over like a bag of hammers if you state in your CA that the auditor didn't understand the definition (even if that's true) 

I had the impression they were referring to their internal auditor being the one who didn't catch it, not the CB auditor. 

It still doesn't explain why the people responsible for pest control weren't doing it, so I don't think it really answers the NC.  Unless the "internal auditor" is somehow the person responsible for pest control?

Some kind of noun confusion here.

I think they are talking about an internal auditor.  

In any case, see the audit as an opportunity to improve.  If you are truly at fault, take the hit. Its' okay to say that you didn't understand something, we learn every day. One key thing to remember, don't blame others or employees. just be transparent. It was something that was overlooked and/or unknown. Put some training in place, corrective action and preventative action. Put some tin cats in the dead space of the drop ceiling and make sure you add it to your pest control program.  I would add some temporary additional monitoring to that area for like a month and based on your trends, resume with normal pest control activates, with the addition of the drop ceiling.

Again, worry less about the blame game and more about the corrective and preventative action.

Sometimes you reach the root cause before you reach the 5th "Why"

Why- failed to be in compliance with (insert section here) regarding drop ceilings

Why- I didn't understand the regulation

Why- lack of knowledge or training regarding regulations

Root Cause- I was unaware of the meaning of the regulation

Corrective Action, see above

Presentative Action- additional SQF training on Pest Control. 

Hi Norcalnate,

Merely being a Devil's Advocate but some external auditors may be "awkward" about using "Training" in RCAs, eg see the SQF Post/Thread below. Personally I don't see an objection.

https://www.ifsqn.co...es/#entry185271

Charles is right.  I've experienced that before.  You cannot just have training as a CA as some auditors will not accept that, so you'll have to tie it together with another CA if you go that route. 

I'd maybe work with your Pest Control provider and have them periodically inspect and document it in a report they give to you.  I'm surprised that they do not inspect this anyway especially if you are in a food facility.

I think they are talking about an internal auditor.  

 

In any case, see the audit as an opportunity to improve.  If you are truly at fault, take the hit. Its' okay to say that you didn't understand something, we learn every day. One key thing to remember, don't blame others or employees. just be transparent. It was something that was overlooked and/or unknown. Put some training in place, corrective action and preventative action. Put some tin cats in the dead space of the drop ceiling and make sure you add it to your pest control program.  I would add some temporary additional monitoring to that area for like a month and based on your trends, resume with normal pest control activates, with the addition of the drop ceiling.

 

Again, worry less about the blame game and more about the corrective and preventative action.

Sometimes you reach the root cause before you reach the 5th "Why"

 

Why- failed to be in compliance with (insert section here) regarding drop ceilings

Why- I didn't understand the regulation

Why- lack of knowledge or training regarding regulations

Root Cause- I was unaware of the meaning of the regulation

Corrective Action, see above

Presentative Action- additional SQF training on Pest Control. 

Yes, want to clarify that our Companies Internal Auditor (SQF Practitioner & employee trained on Internal Auditing) was the one who didn't understand the meaning of "dropped ceilings" and didn't think it applied to our facilities layout.

Below is what we've come up with. I'm new to this company so I'm still catching up on things, though I found that our Pest Control provider has never recommended that we add monitoring to our drop ceilings. There's not even a question on their annual Facility Assessment on dropped ceilings. I've asked they add a question to the Facility Assessment as a Preventative action. They're corporate so doubt they'll do it though I can't believe they never addressed this when we started working with them:

Hi Norcalnate,

Sorry but the Why(1-3) is a semi-complete RCA IMO.

Offhand I suggest the next "Why" could be one of options (1-3) as listed in my previous link (Post 11 current thread), ie Human Error.........

Inasmuch as the RCA is presumably part of a CAPA I suggest that, as in previous link (Post 11 current thread), a Solution is also required. (eg see the worked  example in Post 12 of my previous Link[see Post 11 current thread]).

PS - Note that there are various types of implementaion of RCA, eg see 2nd attachment in previous link (Post 11) which IMEX is more" analytical" than is commonly used in Food business.  Probably should also refer to the Ver 9 SQF Guidance article.

Hi Norcalnate,

 

Sorry but the Why(1-3) is a semi-complete RCA IMO.

 

Offhand I suggest the next "Why" could be one of options (1-3) as listed in my previous link (Post 11 current thread), ie Human Error.........

 

Inasmuch as the RCA is presumably part of a CAPA I suggest that, as in previous link (Post 11 current thread), a Solution is also required. (eg see the worked  example in Post 12 of my previous Link[see Post 11 current thread]).

 

PS - Note that there are various types of implementaion of RCA, eg see 2nd attachment in previous link (Post 11) which IMEX is more" analytical" than is commonly used in Food business.  Probably should also refer to the Ver 9 SQF Guidance article.

Sorry, I'm confused. What would you recommended "Why" be?

Sorry, I'm confused. What would you recommended "Why" be?

OK nevermind think I understand. This is our very first time going through an SQF Audit, would it be a reasonable RCA to state: "The SQF Practitioner and personnel at this Facility are new to SQF and made a mistake on this section" 

If that doesn't work feel free to propose somethign else

OK nevermind think I understand. This is our very first time going through an SQF Audit, would it be a reasonable RCA to state: "The SQF Practitioner and personnel at this Facility are new to SQF and made a mistake on this section" 

 

If that doesn't work feel free to propose somethign else

Hi NCN,

5Whys is a deceptively simple Procedure. :smile:

I have attempted to do a little research into yr situation.

As I understand, you are trying to respond to a scenario which, in a 5Whys-type context, is sometimes handled/simplified as per following extract/attachment -

multiple root causes.PNG   98.27KB   0 downloads

RCA methods.pdf   1022.19KB   40 downloads

As you can see at least 2 root causes are generated for the separated issues. The overall result could probably be analogous to Post 12 inasmuch as one branch focuses on the pest control company and the second on yr internal audit. These could utilize yr # (1-3) comments in Post 13.

(I think the Ishikawa/fishbone approach can diagrammatically handle this kind of situation more easily/less contestably but is more effort to initially set up unless a template is available [an ASQ generic excel is offered on website]).

There are various lengthy Literature publications on whether "Human error" is a valid RC. From a quick look, my evaluation was No. Perhaps "training" is a polite alternative. "Inexperience" seems to be another possible terminology.

PS - Bit late since I see you have satisfactorily submitted a CAR already ! :smile:

Congrats Regardless :thumbup:

Thank you everyone for the suggestions and insights. Our auditing body ended up accepting all our CARs without requests for additional supporting evidence. I panicked at the last moment and provided evidence supporting all our RCA findings. I also ended up adding RCAs along the lines of "This was our first SQF Audit and did not fully understand certain nuanced aspects for complying with section XXX".

SO glad to have gotten the first one under our belt. Less than 10 months ago I didn't know what SQF was. This website, forum and the contributors are such a valuable resource for newbies like me and my company. We worked our tails off to get us up to the SQF baseline; now we can tweek and optimize our system to better comply with certain modules and sections.

Thanks again everyone!

Congratulations NorCalNate! That first audit can be brutal! Know that your knowledge to date was sufficient and that acquiring more will strengthen your system and improve your future audit scores!