Root Cause and People Question - Understanding CAPA's and Root Cause Analysis

[Willyboy]

In trying to understand CAPA's and root cause analysis, I have found myself dazed and confused. I have read some posts, such as Howstes' below from May 2003. In no way whatsoever am I questioning anyone else's understanding of root cause analysis, but instead, I am questioning MY lack of understanding. If anyone wants to try to help clear the fog, (Howste?), I'll be grateful.​

Howste May 2003: "People" should be the absolute last item on the list of preliminary causes. My experience is that way too often people jump to the conclusion that it's somebody's fault, and as soon as they find someone to blame it on, they stop thinking. This is compounded by the fact that the 5-why example ends with a root cause of lack of training. Then, to make it (much, much) worse it has a field that says: "If the cause of the problem involves an employee or contractor please identify the person(s):" Why? So we can counsel, retrain, and/or punish them? The form is setting the stage for corrective actions that aren't focused on the system.”​

Following are some statements/issues which may help to explain my confusion. They all relate to the question: Is this not a “people” problem?​

If a supervisor fails to obtain and/or follow the WIC's for a job and the job is then performed incorrectly.​

If a supervisor fails to train the employees on how to do a job.​

If a truck driver fails to secure their load before leaving the dock.​

If an employee fails to follow safety procedures.​

Another question is in regard to not identifying the person involved with the issue. Why would the QA manager or other management not want to know who is responsible for continuing problems? Take the truck driver not securing their loads from above. If we have two or more drivers, wouldn't knowing who is the recurring cause of damaged goods be important? What about the metrics of this issue? Who is having repeated CARs for not securing their loads, Billy Bob or Suzie Que?​

I do not understand “...setting the stage for corrective actions that aren't focused on the system.” How is it possible to have a system created by and used by humans without using corrective actions focused on the human aspect? If I as an employee continually leave boxes in the walkway or continually fail to secure my truck load, am I not the cause of resulting injuries or damaged goods?​

I hope that I am not sounding too naïve, but my thought process is being seriously challenged.​

Thanks to everyone for their past, present and future input!​

Bill​

 

[Bruser]

Re: Root cause and people question

The root cause is typically not a person but a system. Employee training, work instructions not complete, sample size not large enough, etc.

By directly identifiying the empolyee, the "system failure" will typically end. "Bill screwed up, fire Bill and the problem will be solved". This is not a true statement as their may be many "Bill's" in the company that will do the exact same thing if the reason "Bill" did it in the first place is not corrected.
It maybe that "Bill" just doesn't care, in that case getting rid of "bill" solves the issue. But if "Bill" didn't perform because he didn't have the skill necessary there is a training issue. If "Bill" did what he was told by a supervisor in direct conflict with work instructions, their is a management issue. If "Bill" followed the work instructions but screwed up there may be a documentation issue, ect.

 

[ivanraqa]

Re: Root cause and people question

Willyboy, you are doing yourself a disservice. Do not try to overcomplicate the issue, it can drive you crazy. I've seen some very bright people crashing and burning. Keep it simple, first mitigate the problem, do a root cause analysis (perhaps use a what if analysis), correct the action, verify, come up with plan to prevent the root cause, verify it works and keep vigilance of the issue comes back (maybe missed the true root cause). Over simplified, yes! but it will let you sleep at night and as you get more comfortable with the process, the more complex your analysis.

Hope this helps.

 

[AndyN]

Re: Root cause and people question

Bill:

If you have ever come across Deming's works, you'll know that he postulates that people aren't the problem, the process is. All of the examples you cited are simply that there's an issue with the process. What's more, management's role is to define/provide processes which are low risk of these kinds of failures. As we know, some companies fully embrace this with great results.

Put yourself in the situation of having 'got it wrong'. Can you reasonably be expected to know, for example, all the 'ins and outs' of a job that is new to you, but been done by someone for 15 years? Was all that detail captured in a document? It's often not simply training, it's understanding and awareness - you know that! Compare your own situation when you first got behind the wheel of a car to what you 'take for granted' now......What's different?

Processes should be continually improved - not just for better performance, but often for the purpose of changing personnel etc.

 

[Randy]

Re: Root cause and people question

Ype, it's all a people problem, because RCA is like water flowing downhill...it will always seek the pathway of least resistance, just like most organizational RCA's....call it fixing blame or pointing the finger.

Lets look at some of the stuff from a previous post of yours

If a supervisor fails to obtain and/or follow the WIC's for a job and the job is then performed incorrectly.

If a supervisor fails to train the employees on how to do a job.

If a truck driver fails to secure their load before leaving the dock.

If an employee fails to follow safety procedures.

It was so very easy to stop at these conclusions and there is definite failure of a person here....It's the failure of the person making these statements, and the failure was stopping too soon......

Why did the...

...supervisor fail to obtain and/or follow the WIC's for a job?
...supervisor fail to train the employees?
...truck driver fail to secure their load...?
...employee fail to follow safety procedures?

From these questions we could have possibly identified RC to be a breakdown in the communication process or resourse allocation process or any one of another "system" processes that were not being effectively performed or managed.

When I see stuff like what's in the quoted area above the hoop jumping normally starts

 

[selena15]

Root cause and people question

Hi
just to add this, as folks said, the root cause is a system, not persons
by the way, have a glance one the chapters provided by Graig Cochran on this links
seek of chapter 5 & 4
really interestinggggggg


The Reading Room

Regards

 

[achorste]

Re: Root cause and people question

If you have ever come across Deming's works, you'll know that he postulates that people aren't the problem, the process is.

Wasn't it 90% of the problems are due to the management & only 10% due to the employees - or something of that nature?

My point is although I do agree the vast majority of problems' root causes can be identified as faults in the system (from my, probably insignificant, experience this is tending more towards 99% than the 90% Deming stated), there is still the possibility of an operator being the root cause of a problem and that it may not be prudent to completely discount the operator as a root cause.

 

[howste]

Re: Root cause and people question

In trying to understand CAPA's and root cause analysis, I have found myself dazed and confused. I have read some posts, such as Howstes' below from May 2003. In no way whatsoever am I questioning anyone else's understanding of root cause analysis, but instead, I am questioning MY lack of understanding. If anyone wants to try to help clear the fog, (Howste?), I'll be grateful.​

Actually I posted that less than a month ago here. The point I was trying to make is that often people jump to blame someone for a mistake, then "retraining" is the default action. This will be just as ineffective as "training" was the first time.

As Andy and others have pointed out, we need to focus on having a system and processes designed to ensure that we get results that we need. If the next person will make the same mistake, then our process is not encouraging the behavior that it should be.

AS9110 mentions Human Factors, which is what I believe you're dealing with. "Human Factors" is defined as "Recognition that personnel performing tasks are affected by physical fitness, physiological characteristics, personality, stress, fatigue, distraction, communication and attitude." There are factors that can be controlled within the processes and system to encourage desired behavior. If we make it easy for employees to do the right things and give them proper motivation, then they will probably do the right things. If we make it difficult to do the right things, or we allow other motivations to take priority, we'll end up with bad results. In those cases we shouldn't blame, punish, retrain, etc. We should instead ask why, and try to remove the wrong motivations, make it easier to do it right, make it impossible to do it wrong, etc.

 

[AndyN]

Re: Root cause and people question

there is still the possibility of an operator being the root cause of a problem

And whose job is it to ensure this isn't the case......??? For whatever reason, it's management............

 

[Jim Wynne]

Re: Root cause and people question

And whose job is it to ensure this isn't the case......??? For whatever reason, it's management............

I recall that in a similar thread not long ago, I suggested to someone (who maintained that management is always responsible for errors made by workers) that if he had a method for hiring only people who never make mistakes, he should share it with us.