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Is "Did Not Follow Procedures" Sufficient for RCA?

GStough

Staff member
Super Moderator
#1
When doing Root Cause Analysis, and this cause is identified as the 'root cause', is this ever reason enough? Or does it beg more delving for an even deeper root cause? I'm seeing this identified as the 'root cause' for some corrective actions and it concerns me that people aren't following procedures as they should. If this is happening across several business functions, it would indicate a systemic problem, would it not?

It just makes me want to ask one more 'why?' when I see "did not follow procedures" as a root cause on a corrective action request. :mad:

Thoughts?
 
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R

rjtii51

#2
I see this more often than not for smaller organizations that really do not understand the root cause corrective action process. Typically in root cause you will define the problem statement and while utilizing the 5-Why approach this "response" is typically noted as one of the first Why's. The problem is the supplier/customer is not digging deep enough in the root cause investigation to understand what processes or controls they have in place to prevent an operator from being able to not follow the procedure.

I also have a tough time accepting this as a response, and typically try to work with the supplier/customer to see what other options are available to prevent this issue from re-occurring. I also find it as the "lazy" response out. So typically you will see this response when a supplier/customer does not want to exhaust the effort to find the root cause and can say their operator did not follow the procedure. Most often they will follow that up with explaining how they discussed it with the operator or disciplined the operator and they feel that is the corrective action. Mehhh...
 

Ninja

Looking for Reality
Staff member
Super Moderator
#3
It just makes me want to ask one more 'why?' when I see "did not follow procedures" as a root cause on a corrective action request. :mad:

Thoughts?
FWIW, I am not an auditor...I'm an auditee.

If that were my root cause, I would expect you to ask another "why" or three.

Sometimes 5-Whys are a few too few.
Most Times, the fifth "Why" is filled out first...then the other four are made up to make the form look nice. Sorta defeats the purpose of 5-why, but then most of us auditees question the purpose of 5-why anyway.

My two cents...ask a few more why's.
"I didn't do my job" is not an acceptable root cause...it is the initial problem.
 
#4
When doing Root Cause Analysis, and this cause is identified as the 'root cause', is this ever reason enough? Or does it beg more delving for an even deeper root cause? I'm seeing this identified as the 'root cause' for some corrective actions and it concerns me that people aren't following procedures as they should. If this is happening across several business functions, it would indicate a systemic problem, would it not?

It just makes me want to ask one more 'why?' when I see "did not follow procedures" as a root cause on a corrective action request. :mad:

Thoughts?
No! You need to discover why they didn't follow the procedure. Maybe the procedure was written by someone who never did the job and reads like "War and Peace"...:mg:

There's generally a "reasonable" explanation for why they didn't - awareness, for example. The "Kodak" moment when someone explains why it was important to do "X"...:notme:
 

Jim Wynne

Staff member
Admin
#5
When doing Root Cause Analysis, and this cause is identified as the 'root cause', is this ever reason enough? Or does it beg more delving for an even deeper root cause? I'm seeing this identified as the 'root cause' for some corrective actions and it concerns me that people aren't following procedures as they should. If this is happening across several business functions, it would indicate a systemic problem, would it not?

It just makes me want to ask one more 'why?' when I see "did not follow procedures" as a root cause on a corrective action request. :mad:

Thoughts?
I think it's a question of scale more than anything else. An isolated incident might not need corrective action, and the fact that the same issue has occurred in more than one business function isn't necessarily an indication of a systemic breakdown.

Think about it this way: Suppose, for the category "Following Procedures," There are a few hundred opportunities every day. This isn't a stretch for even some small companies. When procedures aren't followed, generally two things can happen:

  1. Nothing
  2. Something bad
While we need to be concerned about both, it's the second one that causes the most concern, and rightfully so. Nonetheless, given the number of opportunities, the "Something bad" could be insignificant and unfixable.


If you suspect that procedures not being followed is a significant concern, you'll gain little by bouncing the CA responses and asking for a bunch of "whys." Use your internal audit process, especially in those cases where someone has used not following procedures as an answer. See what you can do to help. Maybe procedures are too rigid, maybe there are attitude problems, maybe training is an issue. There could be lots of different causes, but the best thing you can do, imo, is audit and find out what's really going on, and then find out how you can help to fix whatever might be broken.
 

Mikishots

Trusted Information Resource
#6
When doing Root Cause Analysis, and this cause is identified as the 'root cause', is this ever reason enough? Or does it beg more delving for an even deeper root cause? I'm seeing this identified as the 'root cause' for some corrective actions and it concerns me that people aren't following procedures as they should. If this is happening across several business functions, it would indicate a systemic problem, would it not?

It just makes me want to ask one more 'why?' when I see "did not follow procedures" as a root cause on a corrective action request. :mad:

Thoughts?
Yep. more WHYs are needed, if that's the methodology you've chosen. "Did not follow procedures" is no different than "I didn't do it the way I was supposed to". And you wouldn't accept that, would you?

WHY were procedures not followed? Were they not available? Were they unclear? The root cause can lay in the training program (because lack of training itself is not a root cause), document control, D&D....

More examples of no-no's for root cause statements:

- The employee was counselled/talked to.
- Operator error - we retrained him.
- Employee no longer does that job.
- We had to use temps - it's HR's problem.
- Disciplinary process has been put into place.
- Customer used the product incorrectly.
- Replacements have been made.
- We added two more inspectors.
- We fired his a**.
 
I

isoalchemist

#7
I'd look at scale/extent of the issue. If it is 1 of 100's I would not be to concerned, if it was 10% I'd be asking a lot of questions. Sometimes people just mess up and the root cause may as simple as not reading the procedure.:2cents:
 

Jen Kirley

Quality and Auditing Expert
Staff member
Admin
#8
If this happens more than once or twice with a given employee I would start to wonder if there's something going on that the QMS doesn't always recognize. See the list of related threads at the bottom of the page? The top one has my paper in it, titled When Employees Don't Follow Procedures.
 
#9
I'd look at scale/extent of the issue. If it is 1 of 100's I would not be to concerned, if it was 10% I'd be asking a lot of questions. Sometimes people just mess up and the root cause may as simple as not reading the procedure.:2cents:
That's one dimension, but what about the "content" of the procedure? What if it's the "final acceptance" procedure? It's only 1, but wow...
 
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