…if you choose ‘Operator error’ as the cause of your latest non-conformance.
When Ishikawa introduced the world to his ‘Fishbone’ for doing root cause analysis, his research showed that employees in organizations make errors, of course, but only about 6% of the time.
The other 94% of the time,
the error is caused by a
weakness in some other part of our system.
Remember, no one in our organization woke up this morning and asked themselves, “I wonder how badly I can do my job today?”. Humans are hard wired to succeed and we will, given the right tools, the right information (including process information) and the right environment do work in.
Ishikawa suggests that we start with a brainstorming session. He suggests looking in four areas:
1. People (ISO 9001 7.1.2, 7.2)
2. Infrastructure (7.1.4)
3. Work environment (7.1.4), and
4. System, or methods (4.4, 8.5, etc.)
By looking beyond ‘the usual suspects’ we will often find a weakness that we hadn’t noticed and that was a contributor to the unwanted result.
Next, he has us put the ideas into the categories listed above. This works really well, by the way, with flip chart paper and sticky notes.
You may add IT as a category, measurements or any other major contributor to your non-conformance. As an alternative, you can do the brainstorming but choose your categories based on the brainstorm results. This is called an ‘Affinity diagram’.
Finally, choose the most likely candidates (and ones you can control) from 1 or 2 or 3 areas and ask the question ‘Why’ 5 times.
For example, if one of the reasons for a late delivery was ‘The machinery broke down’, the ‘5 why’ exercise might look like this:
The machinery broke down…
#1: Why? Because the preventive maintenance schedule was abandoned
#2: Why was the preventive maintenance schedule abandoned? – Because we were too rushed
#3: Why were we too rushed? Because we were working overtime to clear up backlogged orders
#4: Why were we working overtime to clear up backlogged orders? Because the orders were not scheduled well
#5: Why were the orders not scheduled well? Because the sales and production departments are not communicating with each other
CONCLUSION — the late order wasn’t anyone’s ‘fault’, it was the result of poor communication between departments.
Remember to look beyond the obvious and get to the real root of the problem. You’ll be much more likely to prevent the problem from recurring.
And be sure to ask the question, “If our risk and opportunity activity were more robust, could we have prevented this from happening?”
Happy hunting, and good luck getting to the root cause of your next event!
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