Need advise on Root Cause analysis for printing issue

F

ffemt1

#1
My department is having a lively discussion about the root cause of the problem and I need some expert advice on how to get over the hump. Here is the situation.
We have printing press A that takes printing plates that transfer ink to the paper. When plates are made they require register marks to make sure all of the colors are in register. For whatever reason we need to switch a job to press B after the first set of plates are made. To do this we must make new plates and there is a requirement that for this job, but not all jobs that are switched, “special” register marks are used. The need for these special marks is rare. Well, you guessed it, we did not use the correct marks and printed the job incorrectly.
Now for the root cause.
1. One investigation path takes us down the road of why were the special marks not used. Do we take time to find and implement ways to insure the correct marks are always used? If we can find a way that is foolproof, the problem is eliminated.
2. Second path goes a little further and asks are there a ways to eliminate the need for special marks? (Yes, standardize equipment but might need to spend money and we never like to do that.)
3. Third path goes further and takes us down a different road of why did we have to switch presses in the first place. Is there a way to eliminate the need to switch presses? There may be but it probably takes some preplanning and with extremely quick turn times there are other considerations, like the availability of the correct size paper for the press.

:confused: All are good solutions but isn't there always a best solution? My opinion is that this is like a rework that is done incorrectly. The root cause could be that you did the rework wrong and if you find a way to do it right from now on everything is OK but that is not the actual root cause. The problem is that you were put in the that position in the first place.
Opinions?
 
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Michael_M

Trusted Information Resource
#2
Sometimes a root cause can have multiple reasons, not necessary 'the best'. When this is the case, correct the multiple reasons. Sometimes a CA will even show another potential failure. This can be corrected with a preventive action.

However going a bit further into the CA. Were the (setup) instructions antiquate to the job's and to the two different machines you were using? Did someone verify the printing was correct before 'going into production'?


I am not familiar with printing or printing presses so my additional questions my not apply.
 

insect warfare

QA=Question Authority
Trusted Information Resource
#3
My department is having a lively discussion about the root cause of the problem and I need some expert advice on how to get over the hump. Here is the situation.
We have printing press A that takes printing plates that transfer ink to the paper. When plates are made they require register marks to make sure all of the colors are in register. For whatever reason we need to switch a job to press B after the first set of plates are made. To do this we must make new plates and there is a requirement that for this job, but not all jobs that are switched, ?special? register marks are used. The need for these special marks is rare. Well, you guessed it, we did not use the correct marks and printed the job incorrectly.
Now for the root cause.
1. One investigation path takes us down the road of why were the special marks not used. Do we take time to find and implement ways to insure the correct marks are always used? If we can find a way that is foolproof, the problem is eliminated.
2. Second path goes a little further and asks are there a ways to eliminate the need for special marks? (Yes, standardize equipment but might need to spend money and we never like to do that.)
3. Third path goes further and takes us down a different road of why did we have to switch presses in the first place. Is there a way to eliminate the need to switch presses? There may be but it probably takes some preplanning and with extremely quick turn times there are other considerations, like the availability of the correct size paper for the press.

:confused: All are good solutions but isn't there always a best solution? My opinion is that this is like a rework that is done incorrectly. The root cause could be that you did the rework wrong and if you find a way to do it right from now on everything is OK but that is not the actual root cause. The problem is that you were put in the that position in the first place.
Opinions?
From what you describe, the fundamental issue seems to be a lack of resources. Obviously, if you have sufficient resources (ability to produce/burn plates faster, enough presses to expand flexibility, the correct paper always in stock based on demand, etc.) coupled with good engineering controls, you could say with a high level of confidence that this problem would never recur. Sometimes effective solutions do cost more money than we would like to admit, but the good ones always realize when a more expensive option may be the most viable solution and will fully act to implement it in a timely manner.

I happen to have a little experience in this field, and it is never easy to solve these kinds of problems when there are so many variables to contend with (customer demands, job prioritization, job setup parameters, ordering supplies, press maintenance, operator safety, etc.). In the printing industry, pure reaction to customer's demands can quickly become the nature of the beast, and can leave you in "firefighting" mode all day long if you let it.

Brian :rolleyes:
 

Ronen E

Problem Solver
Staff member
Moderator
#4
Hi,

My opinion is that you can't identify the "best" solution (assuming there is one) before establishing what makes a given solution better or worse. For example, most companies would like to fix their problems while minimising costs. You've hinted that your company is among them. So, ranking the possible solutions may include each solution's associated cost, preferably also taking account of the likelihood of complete solution / durability.

Contrary to response #2 above, I think that implementing more than one effective CA (eliminating one root cause) is not necessary. The important word is "effective". If the action does eliminate the root cause, and it can be demonstrated by objective evidence that this actually removed the possibility of recurrence (or made the chances remote), it should suffice. If the associated risk is high, perhaps some redundancy is required (implement >1 CAs), but otherwise implementing several CAs for a single problem would be - IMO - a waste of resources.

Cheers,
Ronen.
 
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