Root Cause Failure Analysis of a Shipping Error

J Allen

Involved In Discussions
#1
The wrong part was shipped to the Customer. As a result we missed our shipping dealine for required due date. I initiated CA request to shipping and this is what I got:
Cause of Defect: Wrong Parts pulled from Inventory. Why?
Part Number was not matched to pick ticket.
Why Defect was not detected:Shipping clerk did not match Part number with shipper and Certs.
Corrective Action: Inventory and shipping clerks were given a review in procedures to insure diligence in receiving product and preparing part for shipment. Supervisor will monitor for the next month to ensure procedures are followed.
I kicked back the response because it did not address why the inventory clerk pulled the wrong part. I asked if the paperwork was clear, were numbers transposed, was the clerk just careless,....?
I am being told that I am being too "picky" and this is no "big" deal.
Am I? I have to respond to the customer because of this. What could be the real root cause if the paperwork is correct?
 
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tomvehoski

#2
Re: Root Cause shipping Error

It is somewhat weak, but it is one of those human error problems that can't be resolved easliy without beefing up your verification system.

I see the root cause as: A. Human error - pulled the wrong part. B. No process (or process not followed) to verify that the correct part was pulled. If the process was not followed, it must not be a very robust process to go undetected (such as someone double checking that it is actually PN00010000 and not PN 00001000).

It may or may not be a big deal - that is up to your customer, and you. How often does this happen? Did you just shut down your cutomer's 5000 employee plant? Are you losing 25% of your business because of it?

The more important part is the preventive action. Are you prepared to put barcode scanners or other error proofing methods into place to ensure this can't happen again? Is that worth the return on investment? Are issues in your other systems costing you $1million per day while this ended up costing $100?
 

hogheavenfarm

Quite Involved in Discussions
#3
Re: Root Cause shipping Error

If the reply stated that the clerk simply failed to follow procedure because he didn't want to , would that have made it acceptable?
We frequently encounter employees simply bypassing and refusing to follow procedures, either they have a chip on the shoulder, a bad day, or plan on leaving shortly. Getting further into 5Y often turns up things that are not easily fixable,like culture, morale, pride in work, and such. Response requirement times usually make corrective actions of deep seated problems not an option. I'm lucky if I have 10 days to respond with an analysis and a corrective action.
 

Stijloor

Staff member
Super Moderator
#4
Re: Root Cause shipping Error

The wrong part was shipped to the Customer. As a result we missed our shipping deadline for required due date. I initiated CA request to shipping and this is what I got:
Cause of Defect: Wrong Parts pulled from Inventory. Why?
Part Number was not matched to pick ticket.
Why Defect was not detected:Shipping clerk did not match Part number with shipper and Certs.
Corrective Action: Inventory and shipping clerks were given a review in procedures to insure diligence in receiving product and preparing part for shipment. Supervisor will monitor for the next month to ensure procedures are followed.
I kicked back the response because it did not address why the inventory clerk pulled the wrong part. I asked if the paperwork was clear, were numbers transposed, was the clerk just careless,....?
I am being told that I am being too "picky" and this is no "big" deal.
Am I? I have to respond to the customer because of this. What could be the real root cause if the paperwork is correct?
The problem with the "Five-Why" technique is the erroneous assumption that there is only one response to the question "Why?" Usually, there are many more possible outcomes. So, if performed correctly, a Five-Why tree develops. Study the tree. A pattern (a more frequently mentioned possible root-cause) may become visible. Competent users of this technique will also validate selected root causes. Yes folks, there is a lot more to a correctly applied "Five-Why" technique than meets the eye!!

Stijloor.
 

J Allen

Involved In Discussions
#5
Re: Root Cause shipping Error

I'm new to this company, but I have been told that this is a recurring problem. the scuttlebutt is that the no one has really enforced cause/corrective actions and almost any response was accepted. I'm trying to change the culture but I'm having difficulty with managers who say the last guy always told them what to say.
It would not be cost effective to have bar codes and scanners. I just want the people to pay attention to what they are doing.
 

Marc

Hunkered Down for the Duration
Staff member
Admin
#6
Re: Root Cause shipping Error

If the reply stated that the clerk simply failed to follow procedure because he didn't want to , would that have made it acceptable?
We frequently encounter employees simply bypassing and refusing to follow procedures, either they have a chip on the shoulder, a bad day, or plan on leaving shortly. <snip>
No, oh, no. Please tell me that this isn't really happening... :mg: I'd freak out if someone told me that.
 
T

tomvehoski

#7
Re: Root Cause shipping Error

I'm new to this company, but I have been told that this is a recurring problem. the scuttlebutt is that the no one has really enforced cause/corrective actions and almost any response was accepted. I'm trying to change the culture but I'm having difficulty with managers who say the last guy always told them what to say.
If that is the case they probably need training in effective root cause analysis and corrective action. At a minimum they need guidance, so perhaps you could work with them on completing the CA instead of just assigning it to someone.

It would not be cost effective to have bar codes and scanners. I just want the people to pay attention to what they are doing.
Be careful there. "Pay attention to what you are doing" for preventive action is about as weak as "shipping clerk messed up" for root cause. If you have a culture where nothing will be done to fix a root cause, people will realize that finding the root cause is a pointless waste of time.
 

J Allen

Involved In Discussions
#8
Re: Root Cause shipping Error

You are absolutely correct regarding "pay attention to what you are doing." I was just venting that if we all took a better attitude and pride in our work, many of these type of defects would be reduced. I don't want them to throw "dollars after pennies." I want them to make a reasonable effort to find out why? and fix it. After all, our 3rd party auditor will look at our compliance to AS9100 for CA.
 
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tomvehoski

#9
Re: Root Cause shipping Error

You are absolutely correct regarding "pay attention to what you are doing." I was just venting that if we all took a better attitude and pride in our work, many of these type of defects would be reduced. I don't want them to throw "dollars after pennies." I want them to make a reasonable effort to find out why? and fix it. After all, our 3rd party auditor will look at our compliance to AS9100 for CA.
Maybe. It is very possible that they have been down this road before and their preventive action was to change the labels, paperwork, use garanimals, barcodes, etc. but their suggestions were ignored. Unless it is an isolated instance, bad attitude and lack of pride usually have a root cause in the company culture.
 

Jim Wynne

Staff member
Admin
#10
Re: Root Cause shipping Error

The problem with the "Five-Why" technique is the erroneous assumption that there is only one response to the question "Why?" Usually, there are many more possible outcomes. So, if performed correctly, a Five-Why tree develops. Study the tree. A pattern (a more frequently mentioned possible root-cause) may become visible. Competent users of this technique will also validate selected root causes. Yes folks, there is a lot more to a correctly applied "Five-Why" technique than meets the eye!!

Stijloor.
There's another problem with the "Why's" thing that's common to most CA systems. If we go strictly with the evidence at hand in this thread, it appears that the cause might be sitting in the big chair in the front office. If people are continually allowed (and perhaps encouraged) to follow the path of least resistance, that's what they'll do. It's a cultural issue, and unless the source of the problem decides it needs to be changed, messengers will continue to be shot.
 
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