Root Cause Analysis and ISO 9001 - An excellent detailed discussion

Marc

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#1
Root Cause Analysis and ISO 9001

What do you folks think about this??

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From: ISO Standards Discussion
Date: Wed, 19 Jul 2000 10:36:45 -0500
Subject: Q: Cause Analysis /Naish

I have a question regarding cause analysis versus root cause analysis which is four fold.

First, I do not find the word root cause used in the current 9001 or 9002 standard. I see cause. I have had several auditors now who are indicating root cause needs to be performed. In QS it expresses a discipline as to how to get cause analysis but leaves room for the obvious. Is there a requirement in the current standard that requires root cause? If so can you tell me where to find it.

Second, I was recently involved in an audit where the auditor indicated that "all" non conformances required "root" cause analysis including all customer complaints. Is there anyone who can provide information on where this is either a requirement or even some intent of the authors of the standard?

In the standard I see "to a degree appropriate to the magnitude of the problems and commensurate with the risks encountered". This implies to me a company has the ability to decide what the magnitude is and what the risks are and then decide what to do.

Third, in the new standard DIS version I see that a method for doing corrective action is indicated but I do not see there that all non conformances need action. Is there an intent in the new standard to require all non conformances to require such actions?

Fourth, the auditor indicated he did not think the company had done an adequate job of cause analysis because the cause list was a lay-up for a part had not allowed adequate room for cutting. He indicated that that was not sufficient and that the contract review process was not sufficient if they had not done an evaluation at the time of contract review. Where does the standard allow an auditor to indicate a cause is not adequate and insert his own thought on what the cause is and what needs to be done.

The same auditor indicated that the registrar he worked for would find it unacceptable if the cause was ever listed as human error in a case where the investigation showed the employee had been properly trained and had performed the task multiple times before and since correctly.

This statement was made in spite of the fact the employee had a check sheet of the steps they processed which were all checked off and the training and a proficiency test had been performed in the last year. There is no fool proof way to ensure the person does this step except to have the reminder in front of them. Internal audits showed people were signing off the sheet as they went so it was not a rubber stamp process at the end. The client put in an additional step which requires someone else in the department to watch them do the step and sign off on the form to make the auditor happy but this seems like a non value added waste of time for a human error simply because of an auditor.

Phyllis Naish

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From: ISO Standards Discussion
Date: Wed, 19 Jul 2000 11:36:50 -0500
Subject: Re: Cause Analysis /Naish/Hankwitz

Phyllis,

From my perspective, this auditor was way out of line to make such a judgment. The only criteria he could use to make this determination is objective evidence that implementation of the corrective action did not eliminate the problem, period. It is beyond the scope of an auditor's duty to manage or try to second-guess or control your quality operations.

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From: ISO Standards Discussion
Date: Wed, 19 Jul 2000 11:55:24 -0500
Subject: Re: Cause Analysis /Naish/Scalies

From: Charley Scalies

> First, I do not find the word root cause used in the current 9001 or 9002
> standard. I see cause. I have had several auditors now who are indicating
> root cause needs to be performed. In QS it expresses a discipline as to how
> to get cause analysis but leaves room for the obvious. Is there a requirement
> in the current standard that requires root cause? If so can you tell me where
> to find it.

Unless you have found the root cause(s), you have not found the cause(s). I would no more stop looking for the root cause until I was fairly certain I had found it, than I would continue looking for something I had lost after I had found it.

> Second, I was recently involved in an audit where the auditor indicated that........

Without repeating the balance of your entire post, I offer two comments:

1. You seem to have your head screwed on straight.

2. I am too polite to tell you where I think that auditor's head is.

God save us from auditors/registrars who are either "cowboys" or who haven't a clue of what it's all about! Whenever you find an auditor - internal, external or infernal - who tells you something that sounds like it absolutely flies in the face of common sense and good business practice:

1) He/she did not explain it to you properly and/or

2) He/she hasn't got a clue! (ISO9000 -any version you like- is designed to make good business sense. Any interpretation to the contrary is uninformed or wrong-headed.)

I suspect some of my colleagues may take me to task for such sharp opinions but, while I believe that discussion and debate over the meaning and intent of the standard's requirements is a very good and healthy thing, parsing (Philadelphia Lawyering) those requirements to the point of arbitrarily imposing non value added activities (and I consider a registration certificate to have near zero real value) lies somewhere on the continuum of incompetence, malfeasance and outright theft. I have no time and even less patience for it.

Charley Scalies

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One More.........
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From: ISO Standards Discussion
Date: Wed, 19 Jul 2000 12:49:21 -0500
Subject: Re: Cause Analysis /Naish/Andrews

Phyllis wrote ;
"I have a question regarding cause analysis versus root cause analysis which is four fold. First, I do not find the word root cause used in the current 9001 or 9002 standard. I see cause. I have had several auditors now who are indicating root cause needs to be performed. In QS it expresses a discipline as to how to get cause analysis but leaves room for the obvious. Is there a requirement in the current standard that requires root cause? If so can you tell me where to find it."

Comment: Although the word "root" is not used in the Standard (ISO 9001-1994), I have always interpreted "cause" to mean "Root Cause" - else what's the point?

"Second, I was recently involved in an audit where the auditor indicated that "all" non conformances required "root" cause analysis including all customer complaints. Is there anyone who can provide information on where this is either a requirement or even some intent of the authors of the standard?"

Comment: The auditor is way off the mark on thinking that ALL nonconformances require root cause analysis. There is no such requirement in the Standard. That being said, I would certainly think that a formal customer complaint was of a SIGNIFICANT enough nature to warrant performance of root cause analysis (providing that it was a valid complaint).

"In the standard I see "to a degree appropriate to the magnitude of the problems and commensurate with the risks encountered". This implies to me a company has the ability to decide what the magnitude is and what the risks are and then decide what to do.

Comment: I agree

"Third, in the new standard DIS version I see that a method for doing corrective action is indicated but I do not see there that all non conformances need action. Is there an intent in the new standard to require all non conformances to require such actions?"

Comment: That is not my interpretation; however, others on this list may see it differently

"Fourth, the auditor indicated he did not think the company had done an adequate job of cause analysis because the cause list was a lay-up for a part had not allowed adequate room for cutting. He indicated that that was not sufficient and that the contract review process was not sufficient if they had not done an evaluation at the time of contract review. Where does the standard allow an auditor to indicate a cause is not adequate and insert his own thought on what the cause is and what needs to be done."

Comment: The auditor was WAY WAY over the line on this one.

"The same auditor indicated that the registrar he worked for would find it unacceptable if the cause was ever listed as human error in a case where the investigation showed the employee had been properly trained and had performed the task multiple times before and since correctly."

Comment: Human error is sometimes an acceptable cause - PROVIDED all of the other necessary elements (training, documentation, equipment, etc. ) have been fulfilled. The problem is that sometimes human error is used as a cause without digging further to uncover the 'true' root cause of the problem.

"This statement was made in spite of the fact the employee had a check sheet of the steps they processed which were all checked off and the training and a proficiency test had been performed in the last year. There is no fool proof way to ensure the person does this step except to have the reminder in front of them. Internal audits showed people were signing off the sheet as they went so it was not a rubber stamp process at the end. The client put in an additional step which requires someone else in the department to watch them do the step and sign off on the form to make the auditor happy but this seems like a non value added waste of time for a human error simply because of an auditor."

Comment: This last part REALLY upsets me. It highlights one of the main negative aspects of third party auditing. The poor unfortunate company has now installed an additional, ZERO value added, step into their operation just to placate this, obviously under trained, auditor. Their corrective action for this situation, if they had uncovered the true ROOT CAUSE, should have been to toss the auditor out on his/her derriere.

Ethan Andrews

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Left Overs
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From: ISO Standards Discussion
Date: Wed, 19 Jul 2000 12:59:26 -0500
Subject: Re: Cause Analysis /../Scalies/Taormina

From: Charley Scalies
<< I suspect some of my colleagues may take me to task for such sharp opinions but, while I believe that discussion and debate over the meaning and intent of the standard's requirements is a very good and healthy thing, parsing (Philadelphia Lawyering) those requirements to the point of arbitrarily imposing non value added activities (and I consider a registration certificate to have near zero real value) lies somewhere on the continuum of incompetence, malfeasance and outright theft. I have no time and even less patience for it. >>

Are you kidding? You don't go far enough! Those who believe that ISO 9000 is prescriptive, literal and dogmatic should be taken out and shot. The standard does not say that (for profit) companies should have a profit motive. Does that mean we have to wait until the 2005 revision to start working on quality being a value add instead of a cost center? The last time I had to use my claw hammer I used the tool for the purpose which effectively fit my application, driving nails. I did not use it to remove a fly from my friend's forehead.

Tom Taormina
 
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Marc

Hunkered Down for the Duration
Staff member
Admin
#2
From: ISO Standards Discussion
Date: Thu, 20 Jul 2000 10:32:58 -0500
Subject: Re: Cause Analysis /../Naish

I appreciate the responses I have gotten so far on this. After sending the post I thought more about it and had a discussion this morning with the registrar involved but with their corporate person rather than the auditors.

In our discussion he agreed that the issues I had presented were a concern to him. He felt that the auditors had gone over board on their statements and would ensure at their next training session ALL of their auditors would review the requirements versus opinions.

As to my point on cause versus root cause I may not have explained that even though we said the person "forgot" or what ever, the auditor said that was only proximate cause and that the root cause as to why he forgot was needed. In response we said he could of had a sick family member, a fight at home, wasn't feeling good, or was thinking about some plans for the night. He could not say why he forgot and we saw no reason to take it any farther than we had. (this is the check sheet example from before). He said he would let it go but he was not comfortable that we had gotten to "root" cause since we didn't know why this occurred. We had only gotten to cause.

Thanks again for the responses which concurred with what I thought.

Phyllis Naish

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From: ISO Standards Discussion <[email protected]>
Date: Thu, 20 Jul 2000 10:43:27 -0500
Subject: Re: Cause Analysis /Naish/vanPutten

> I have a question regarding cause analysis versus root cause analysis which
> is four fold.
> First, I do not find the word root cause used in the current 9001 or 9002
> standard. I see cause. I have had several auditors now who are indicating
> root cause needs to be performed. In QS it expresses a discipline as to how
> to get cause analysis but leaves room for the obvious. Is there a requirement
> in the current standard that requires root cause? If so can you tell me where
> to find it.

Root cause is the reason for the problem. There may be an escape cause, special cause, common cause ( etc.) in addition to the root cause or as part of the root cause. There are many types of causes in problem solving. Therefore, only cause analysis is identified. You will have to decide which type of cause is to be analyzed. Hopefully, you are always identifying the root cause (whether common or special) when analyzing problems or nonconformities. In addition, you may have to identify an escape cause or other types of causes. The IDS of ISO 9000:2000 only states "determine causes of nonconformity" 8.5.2 b

> Second, I was recently involved in an audit where the auditor indicated that
>"all" non conformances required "root" cause analysis including all customer
> complaints. Is there anyone who can provide information on where this is
> either a requirement or even some intent of the authors of the standard?

The problem here may be the difference between cause analysis and corrective action. I would say that cause analysis should be done for every nonconformity. You should determine the cause of the problem. However, corrective action is required only based on the impact of the problems encountered. What was the problem? How bad was it? Do we need to correct it?

> In the standard I see "to a degree appropriate to the magnitude of the
> problems and commensurate with the risks encountered". This implies to me a
> company has the ability to decide what the magnitude is and what the risks
> are and then decide what to do.

Agreed. But this can only be done after you analyze the cause.

> Third, in the new standard DIS version I see that a method for doing
> corrective action is indicated but I do not see there that all non
> conformances need action. Is there an intent in the new standard to require
> all non conformances to require such actions?

I think this should be answered by someone more experienced from the ISO/TC 176.


> Fourth, the auditor indicated he did not think the company had done an
> adequate job of cause analysis because the cause list was a lay-up for a part
> had not allowed adequate room for cutting. He indicated that that was not
> sufficient and that the contract review process was not sufficient if they
> had not done an evaluation at the time of contract review. Where does the
> standard allow an auditor to indicate a cause is not adequate and insert his
> own thought on what the cause is and what needs to be done.

>> From my perspective, this auditor was way out of line to make
>> such a judgment. The only criteria he could use to make
>> this determination is objective evidence that implementation
>> of the corrective action did not eliminate the problem, period.
>> It is beyond the scope of an auditor's duty to manage or try to
>> second-guess or control your quality operations.

> The same auditor indicated that the registrar he worked for would find it
> unacceptable if the cause was ever listed as human error in a case where the
> investigation showed the employee had been properly trained and had performed
> the task multiple times before and since correctly.

This is true for some automotive customers also. What these groups are driving towards is that most often the problem is with the system that provided the training. How many human beings do you know that do not try to do a good job or that purposely try to do a bad job? Human behavior usually dictates that a person will try to maintain some pride and do a good job. Can the process be mistake proofed? Is the training program effective? Where all necessary tools provided? Was a system of motivation implemented to continue to do the job correctly? Training or human error can quickly become an easy out for corrective actions.

Dirk van Putten

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From: ISO Standards Discussion
Date: Thu, 20 Jul 2000 10:44:57 -0500
Subject: Re: Cause Analysis /../Scalies/Taormina/Arbuckle

Phyllis:

I had planned to take the time to respond to your post, but found that others (Mr. Scalies, Mr. Andrews and Mr. Taormina) have clearly and more than adequately stated everything I would have said. I wish I could add more, other than to let you know that that auditor would be out of my client's so quickly, they would not have had much time to negatively impact the client more than they may have already done. [I have "bounced an auditor" twice in my career and both times the registrar agreed with my request by terminating those auditor's contracts/employment. I am sure they had had other problems with them and that my incident was not the only determining factor!]

re: "In the standard I see "to a degree appropriate to the magnitude of the
problems and commensurate with the risks encountered". This
implies to me a company has the ability to decide what the magnitude is
and what the risks are and then decide what to do.

That is there to allow an organization the opportunity to take a look at the cost and impact of the change. (i.e. One customer complaint that could be resolved with a high-dollar fix that may not ever occur again anyway....)

At any rate, listen to those I mentioned above, they are 100% right on!

Don Arbuckle

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From: ISO Standards Discussion
Date: Thu, 20 Jul 2000 10:48:39 -0500
Subject: Re: Cause Analysis /Naish/Whitcomb

Phyllis and Other Respondents:

I would agree with most everything all the other respondents have said. I went to the standard looking for the term "root cause" and it "ain't there". However, I did find the term used in ISO 9004-1:1994(E) paragraph: 15.5 Analysis of problem . I only point this out in that, I know, some auditors like to say ISO 9004 is a better standard and tend to look for bits-n-pieces of that standard in the implementation of ISO 9001-2-3.

Next, I did find another reference to Nonconformance's in ISO 9000-2:1993(E) (Why I have all this is beyond me; must have at one time enjoyed reading all I could get my hands on!!) and this states in paragraph 4.14 Corrective Action in Note #3, "Corrective action is not necessarily required for every occurrence of a nonconformance, but periodic analysis of patterns of nonconformances should be considered to uncover opportunities for process improvements". Sounds an awful lot like a common-sense approach to me.

Good luck
Gary
 

Marc

Hunkered Down for the Duration
Staff member
Admin
#3
From: ISO Standards Discussion
Date: Fri, 21 Jul 2000 10:23:52 -0500
Subject: Re: Cause Analysis /../Whitcomb/Taormina/Whitcomb

Tom: Your statement:
"That's why my previous post was intentionally absurd to stimulate users not to look for literal remedies within the standard." does not play, or I should have said, did not play out well, in my Lead Auditor training, as "root" cause was a topic that we were led to believe was a very important issue. I am afraid the 9004 guidance document used the term "root cause" in not such an absurd way, when it says: "In the analysis of a quality related problem, the root cause or causes should be determined first before corrective action is planned". (ISO 9004-1:1994(E)).

While I certainly come down on your side, I am afraid some auditors have used the guidance documents as more or less an "expectations document" when auditing a system. Which brings to mind an interesting question: If we were not to have used the 9004-1 or other guidance documents in developing our systems, why did ISO go to such great lengths in developing such guidance documents? And if from what I hear and see, the 9k-2K version is meant to be a companion document to 9004-2000 what does that mean? If not clarified, I think we will get some of the same type interpretations.

Gary

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From: ISO Standards Discussion
Date: Fri, 21 Jul 2000 10:28:38 -0500
Subject: Re: Cause Analysis /Naish/Summerfield

From: George

Hi Phyllis:

First of all, I'd like to say that I agree with almost everything stated by the others in the list, regarding this incident. First: I believe that the term "Root Cause" is borrowed from TQM, and more specifically: Joseph Juran. That's been hashed over enough though. Second - No - not ALL nonconformances have to be removed, but they do have to be analyzed (Risk Analysis) to determine if they are cost-worthy toward removing, or if the overall process would suffer more so through too much tampering. There are two main methods to incur error with a process from statistical data gathering: missing an opportunity for improvement and improving too much so as to incur more variation further down the line. Please don't dismiss this as being way off base. You can over-compensate in the correction of nonconformances too, and incur REAL problems in other areas of the process (i.e. slam the worker for making the human error and incur a work slow-down by him/her and other workers who feel that this quality system is just a little too unforgiving).

A few in the list have eluded to what I'm going to share with you next - giving you food for thought. The auditor was way out of line presenting his findings the way that s/he did; but consider the history of flight. Yes, mankind has been taking to the skies in mechanical ways for more than 90 years - and yet, irrespective of extensive complex training, state-of-the-art communications/weather and terrain avoidance aids, numerous checklist (not to mention Documented Procedures, auditing and testing galore), and excellently documented and shared accident investigations, as well as the sharing of the findings; airplanes still manage to crash due to pilot error. Go figure!

Now to the point: here in the aerospace industry we've taken to categorizing Human Error into possible Cause Factors (i.e. Fatigue, Inattention, Judgement Error, Non-compliance with orders, etc.). The list goes on - but the point is made. If you can categorize the cause for the human error, then treat it; then no auditor would ever be able to complain that the nonconformance was not duly attended to. The staff of the company will probably appreciate the turn in the quality initiative to treat the causes of most of their discomforts too, which may be causative in the incident of human error. Anyway, your non-value added fix seemed to indicate (at least to me) that you're treating the symptom, rather than the cause. You don't have to come up with all of the Cause Factors that we use, but giving some consideration to them could help you in analyzing whether its worth fixing, or an isolated incident; or whether you're treating a cause as opposed to a symptom. Good luck...

George

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From: ISO Standards Discussion
Date: Fri, 21 Jul 2000 11:47:55 -0500
Subject: Re: Cause Analysis /../Whitcomb/Arbuckle

> While I certainly come down on your side, I am afraid some auditors have
> used the guidance documents as more or less an "expectations document" when
> auditing a system. Which brings to mind an interesting question: If we were
> not to have used the 9004-1 or other guidance documents in developing our
> systems, why did ISO go to such great lengths in developing such guidance
> documents? And if from what I hear and see, the 9k-2K version is meant to
> be a companion document to 9004-2000 what does that mean? If not clarified,
> I think we will get some of the same type interpretations.
>

While I am not sure if you fall into this category or not, for many years, people believed that ISO 9004 was a "roadmap" for implementing ISO 9001. This was never the intent of that document, however that is how it has been used. The writers of the new version have attempted to clarify this position and have done so in the text of ISO/DIS 9004, section 0.3. Although summarized here, I invite others to review what the draft says about the relationship between ISO 9001:2000 and ISO 9004:2000. Generally, the text points out that they are a "consistent pair". That the benefits are likely to be more extensive if both are used, rather than just implementing one. That the two documents really have two different scopes. ISO 9001:2000 is designed to be used where an organization needs to demonstrate ability to consistently provide product that meets requirements. ISO 9004:2000 is designed to provide guidance to improve the organization's overall performance.

>From ISO 9004:2000, "This International Standard is not a guideline for implementing ISO 9001..."

While it makes a great deal of sense to review ISO 9004:2000 during implementation, it should be done with an eye toward what can be done additionally to improve the organization, as ISO 9001 is being implemented. But clearly, the statements which appear on ISO 9004 are not auditable in an ISO 9001-based registration audit as per ISO/DIS 9004:2000, Section 1, which states that this standard (ISO 9004) "is not intended for certification, regulatory or contractual use."

Hope this helps....

Donald A. Arbuckle

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From: ISO Standards Discussion
Date: Fri, 21 Jul 2000 11:52:22 -0500
Subject: Re: Cause Analysis /../Taormina/Whitcomb

Tom and Others:

Tom wrote in part of one of his replies: "ISO 9000 and its implementation guidelines encourage us to use the tools that are appropriate to our culture and applications".

I would like to ask a hypothetical question concerning this "root cause" point, as it relates to ISO 9000-2000 and auditing. A bit of background prior to the question: In the DIS-9K-2K there isn't any mention of "root cause". However in the DIS 9000-4 there are several places it mentions using root cause analysis ( 8.5.2 and Annex B: process methodology for improvement c-f second paragraph). Now my question:

"Would/Could/Should a certifying auditor have a reasonable expectation that some sort/form of root cause analysis be used and/or expected to be used, for meeting the intent of 8.4, and 8.5 of ISO DIS 9000-2000 even though root cause is not mentioned"?

I would like to hear some interpretations to this. Tom's point, and a good one I think, is that his client need not use this type analysis and to use tools that are appropriate to their cultures. It seems to me 9K-2K and DIS 9004 are placing more of an emphasis on this type analysis than in the 94 version.

Thanks for any replies and comments. Basically the reason for this dialog is that we have done a good job of identifying corrective actions, and not so hot in the preventive action area. We have discussed the "root cause" issue and our auditor, while not giving us finding, has observed we should do a better job at this. I guess I am wondering if this will be a bigger deal with 9K-2K.

Gary
 

Marc

Hunkered Down for the Duration
Staff member
Admin
#4
From: ISO Standards Discussion
Date: Mon, 24 Jul 2000 09:24:06 -0500
Subject: Re: Cause Analysis /../Whitcomb/Kozenko

> I would like to ask a hypothetical question concerning this "root cause"
> point, as it relates to ISO 9000-2000 and auditing. A bit of background
> prior to the question: In the DIS-9K-2K there isn't any mention of "root
> cause". However in the DIS 9000-4 there are several places it mentions
> using root cause analysis ( 8.5.2 and Annex B: process methodology for
> improvement c-f second paragraph). Now my question:
>
> "Would/Could/Should a certifying auditor have a reasonable expectation that
> some sort/form of root cause analysis be used and/or expected to be used,
> for meeting the intent of 8.4, and 8.5 of ISO DIS 9000-2000 even though
> root cause is not mentioned"?
>

I've enjoyed these posts from the perspective of "degree of risk" and I think that's where the real answer lies.

If the degree of risk involves "parts per billion" then there's one thing to do; if it involves "one-quarter inch plus or minus one-sixteenth" (or the metric equivalent) then that's quite another matter. And THAT is the chief problem in applying Standards to EVERY industry.

Either way, it does place the Registration Auditor in the (awkward ;o) position of having to decide if his/her opinion or assessment of what might be called for in a given situation, is in fact "crossing the line."

IMHO, the current trend in this thread is that an auditor suffering from "expertisium displacia" was too outspoken, coupled with an auditee suffering from plain ole' paranoia (also known as not being able to see the forest from the trees, the latin equivalent of which escapes me, but for lack of the time to quote an esteemed colleague of ours on this list who frequently posts, and who has used such in a marvelously appropriate way).

David M. Kozenko
 

Marc

Hunkered Down for the Duration
Staff member
Admin
#5
From: ISO Standards Discussion
Date: Mon, 24 Jul 2000 09:35:02 -0500
Subject: Re: Cause Analysis /../vanPutten/Naish

Dirk,

The person had a check sheet which they had supposedly checked off as they went. They had been trained and doing the job for quite some time and had passed a proficiency test in the last year. This only occurred once in the last two years. The auditor wanted us to find out why he forgot. Even the person could not say why.

The company has had only 9 corrective actions, including audit findings where the procedure had a title wrong (due to a promotion), in the past year. And none of them have been a repeat of previous and only the one mentioned and the title change one were listed as human error.

I have seen several responses about human error that bother me. While I absolutely agree that we need to be careful about over using human error, we have to be aware that we are human beings and therefore can make mistakes. And while these emails may not be a fair guide to what we should expect from an employee as there is no procedure or standard set, I find it extremely interesting that in several of the emails there were human errors made as to spelling or choice of word which only points out we are human and can make mistakes.

Several of you agreed it has to be appropriate to the problem while others said get to the cause. I have been in companies who had people who had time to spend all day or even days tracking one problem and spent thousands to find the source of a nickel problem. I have to think the writers of the standard had a little more business sense than to think this is practical in the world today.

If a problem is recurring then I think we need to look at the problem closer and do better cause analysis. If the problem is not recurring, the problem solving is a non value added process that buys a business nothing and buys the customer less since the price of goods reflects the costs of business which includes time wasted on non value added processes.

Phyllis Naish
 

Marc

Hunkered Down for the Duration
Staff member
Admin
#6
From: ISO Standards Discussion
Date: Mon, 24 Jul 2000 13:16:58 -0500
Subject: Re: Cause Analysis /../vanPutten

I do not mean to imply that human error can be eliminated or is never the "root cause". I would wonder about a human error for a "lay-up for a part had not allowed adequate room for cutting" depending on if it was in prototype, pre-production, or production stage. It is all part of "Corrective action shall be appropriate to the impact of the problems encountered" DIS ISO 9000:2000 8.5.2. If the problem occurred in prototype, then the impact would not be that great because prototype is all about getting the product right before production. If the inadequate room for cutting made it all the way to production, then I would begin to think about the impact of the problem.

When a person tries to determine if the problem is recurring or not, they have already begun an analysis of the problem. Also, I am careful not to only look to the past during the analysis of recurrence and impact. A problem could have only happened once so it is not recurring, but may have a tremendous impact from that one occurrence or there may be reason to believe the process will allow it to happen again. The nature/impact of the occurrence, past data, and potential future occurrences/impact, all feed into the overall impact of the problem and help us determine whether corrective action is needed. But with out some type of cause analysis, we cannot determine whether corrective action is necessary. This cause analysis does not have to be an all day affair or a full time job.

I think it is very important that we separate "cause analysis" from "corrective action". How can anyone determine if corrective action is necessary without a least a little "cause analysis".

In terms of human error, I have quoted below, my favorite response so far that I believe recognizes human error is part of every system. It is what you do with the "human error" data that makes a difference.

Dirk

-------------------------

From: ISO Standards Discussion
Date: Mon, 24 Jul 2000 13:21:21 -0500
Subject: Re: Cause Analysis /../Naish/Scott

Naish states <snip>: "If the problem is not recurring, the problem solving is a non value added process that buys a business nothing ..."

While I wholeheartedly agree that spending thousands to save nickels is foolish, it is crucial that all sources of costs be considered when adding up the nickels.

I have a little more difficulty with the snipped statement above. Some problems, depending on cost in dollars (or lives) must be resolved even if they happen only once.

Cordially,
Phil
 
D

David Mullins

#8
My recent experiences with external auditors, 9001:2000 and root cause has been the same as Phyllis.

Inconsistency of interpretation (yes, that horribly emotive term of which much has been previously discussed) isn't acceptable, but apparently tolerable.

Roll on 2005, and more interpretations.

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