I witnessed a strange event while facilitating a RCM Blitz™ recently. We were discussing the causes of why product labels were not being applied or misapplied to bottles. After listing the first five or six causes someone on the team stated the labels could also be placed upside down on the bottle if they weren’t properly placed in the magazine.
The line supervisor quickly perked up and asked is that a training, design, systemic or human cause?
The maintenance mechanic in the room was first the take the bait; “Well it’s either a human or training related, but aren’t they the same thing? I mean it one thing if the operator put them in upside down if they were trained to do it the right way, but if they just did it accidently well that’s another issue. I wonder if there is a way we can change the magazine or the label so that they can’t go in upside down.”
I decided to jump back in before the conversation wandered even further into the woods stating; if it’s ok I would prefer to hold of attaching labels to causes. Looking back at the person who had stated that it was possible to place the labels upside down in the magazine and asked; what would cause someone to place the labels upside down in the magazine?
“There are a few causes but most often it happens when someone opens the case of labels upside down.”
The team went on to list eighteen more failure modes that resulted in missing or misplaced labels and at lunch the line supervisor asked me why I didn’t want to label each cause and place them in proper categories.
Here are my thoughts;
While having categories for failure modes might make sense in regard to organizing causes, in my experience it tends of often more confusion and slows the process of failure mode discovery. I don’t care for it while facilitating RCM and I don’t use the technique when facilitating a Root Cause Analysis either. In my mind the process of solving problems starts with first identifying the problem, and then moves on to identifying potential causes. The process of categorizing these causes if you feel the need should occur as you then move on to prove or disprove a cause.
Categorization also lends itself to being the first step of blame; “These failures are process based, who is responsible of writing the operations procedures….The next thing you know that person has a name and someone is a the process of solving problems starts with first identifying the problem, and then moves on to identifying potential causes. The process of categorizing these causes if you feel the need should occur as you then move on to prove or disprove a cause.”
Categorization also lends itself to being the first step of blame; “These failures are process based, who is responsible of writing the operations procedures.”
The next thing you know that person has a name and someone is asking why this wasn’t taken care of before the failure occurred.
Eliminating failures at your facility depends on open, honest and unimpeded facilitation of tools and if you want people to participate everyone must be confident the process is going to move forward without blame.
As always I am interested in your thoughts as well, what has been your experience in regard to labeling failure causes?
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