D5 of 8D clarification, how to verify root cause

[RoxaneB]

Thanks Rox, I got what you say,

Please, my name is Roxane. There are only a handful of people in the world that I'm okay to hear any other variation of my name from.

Let´s say these are root causes, as actions to eliminate them, could apply to give these employees awareness talks, additionally to check authorities/responsibilities , maybe they don´t know exactly their frontiers of actions ? or what is recommended?

Ummmm...sure, you could give awareness talks to the supervisor about the importance of not assigning an untrained person (based on my example scenario) or to the operator for not speaking up. But again, if you carefully read what I wrote, I did not actually offer a root cause....one still needs to dig deeper to understand WHY the supervisor assigned an untrained person in my example...or WHY the operator did not speak up.

It really sounds like you are trying to fix superficial issues...those immediate issues that you see. To do a true corrective action, you need to DIG DEEP. Pretend you are a child and ask WHY WHY WHY until you get to the real reason. When the people involved start to feel uncomfortable, odds are you are getting to closer to the real reason.

Look, if someone has a deep cut on their leg, you don't just put a bandage on it to "stop" the bleeding. All that the bandage does is stop the blood from going every where and making a mess. It doesn't address the real reason behind the bleeding. Even applying a tourniquet isn't addressing the real root cause - it may stop the bleeding from coming out of the bound, but it does not stop the reason behind WHY the bleeding is happening. A deeper investigation into the source of the bleeding will help understand WHY the person is bleeding so that way the appropriate medical care can be taken to truly stop the root cause.

The first, little or none training, the second, no follow-up of the schedule of training by the training responsible.
there were scheduled training, but the responsible of the schedule (who hires the trainer, assign resources,etc.) forgot
to do it.

So....based on what many of us have repeatedly been asking you...WHY did this happen? WHY was training forgotten?

 

[qualprod]

And I'm not sure you (qualprod) are actually understanding what we are saying.

Operator training is never a root cause. There is always a deeper causal mechanism. And retraining the operator is never an acceptable corrective to prevent recurrence. The fact that you are struggling to determine for test for the effectiveness of this 'corrective action' is a sure sign that retraining the operator is not a corrective action that prevent recurrence.

Qualprod do you disagree with this position?

Jim, is a real case.

Bev D.
I want to refresh the case, so that can be understood very clear.

My original post was this:
But in the case that a root cause is lack of training for an operator, how to ensure if this will work?
how to simulate or do a pre-testing?
To train this operator and wait until works?[ this will take a long time , weeks or months and the CA, have to be solved quickly,
or by having evidence of similar trainings with other people?

Because my main concern was how how to test actions to ensure your plan will work, per requirement of 5D
The pre -testing or simulations.
Someone suggested, to perform a similar training with other people, not the one who caused the non conformance, up to here
was understood for me.
Then Roxanne, adviced to go deep in this issue (good idea) , root cause was not the operator training, maybe who asked him/her to do it and
why the operator didn´t refuse to do it, knowing, he/her was no trained.
Now, both recommendations for me, are good advices.
i hope it is more clear now.

 

[RoxaneB]

Then Roxanne, adviced to go deep in this issue (good idea) , root cause was not the operator training, maybe who asked him/her to do it andwhy the operator didn´t refuse to do it, knowing, he/her was no trained.

I will say this again, @qualprod , my scenario was an example. I do not know if it applies to your situation. If it does, great...just make sure that the conversation is not accusatory or like an interrogation. At no point should anyone feel like they are to blame. Root cause should not be about blaming people.

 

[qualprod]

Please, my name is Roxane. There are only a handful of people in the world that I'm okay to hear any other variation of my name from.



Ummmm...sure, you could give awareness talks to the supervisor about the importance of not assigning an untrained person (based on my example scenario) or to the operator for not speaking up. But again, if you carefully read what I wrote, I did not actually offer a root cause....one still needs to dig deeper to understand WHY the supervisor assigned an untrained person in my example...or WHY the operator did not speak up.

It really sounds like you are trying to fix superficial issues...those immediate issues that you see. To do a true corrective action, you need to DIG DEEP. Pretend you are a child and ask WHY WHY WHY until you get to the real reason. When the people involved start to feel uncomfortable, odds are you are getting to closer to the real reason.

Look, if someone has a deep cut on their leg, you don't just put a bandage on it to "stop" the bleeding. All that the bandage does is stop the blood from going every where and making a mess. It doesn't address the real reason behind the bleeding. Even applying a tourniquet isn't addressing the real root cause - it may stop the bleeding from coming out of the bound, but it does not stop the reason behind WHY the bleeding is happening. A deeper investigation into the source of the bleeding will help understand WHY the person is bleeding so that way the appropriate medical care can be taken to truly stop the root cause.



So....based on what many of us have repeatedly been asking you...WHY did this happen? WHY was training forgotten?

Sorry , from now and on, RoxaneB
I really appreciate your precious time to help me.
Thanks you too much.

 

[Johnnymo62]

This may be useful for you.

 

[normhowe]

Perhaps this is a language thing but let’s clarify that the means that are used to verify that the identified root cause is in fact the root cause you may use any of several means depending on what is appropriate - you do not have to use all of the suggested means. So you don’t always have to use simulation. Essentially what you have to do is turn the cause ‘on and off’ and ensure that the Problem is turned on and off.

Second your example of lack of operator training is simply NOT EVER a ROOT cause. A root cause is actionable such that reducing or eliminating or countering it teh problem wil not recur in the future. So Jim’s question is getting at exactly that issue.

YES. So, I'm going to put that operator back through the same training regime that allowed the error to happen in the first place and expect a different result! What's that the definition of?

 

[Jim Wynne]

So, I'm going to put that operator back through the same training regime that allowed the error to happen in the first place and expect a different result!

How do we know that the "training regime" caused the error?