One root cause or several ?

Hi everybody
I share a case of a non conformity for your feedback.

Case:
-Defective product in machine

Questioning participants:
-Operator explained he was doing his best efforts, but didnt know the machine.
-Also, parts in the machine were found damaged because of misuse.
-Supervisor, explained he didnt know exactly at what extent he had to evaluate this guy.
didn´t know in detail what to consider, in fact, he told the form was simple and generic.
in order to evaluate all aspects needed. Into this lack of data to evaluate, it was
what caused the operator to make mistakes, and inadequated use of the machine and parts
damaged resulted.
The key lacking point it was " full experience in setting up the machine in cold temperature" .
Human Resources, said hired what was required.

Recruiting people process:
-Supervisor, requires this guy to Human resources.
-Human resources requires to fill out some forms.
-in the form are described the abilities required.
-Based on this, HR hires this guy.
-Before the hiring (one test is run),supervisor acccepts or rejects person, in this case was accepted.

Root cause = Form lacking enough and important requirements when hiring technician in XXX machine"

As action plans to complete the corrective action are:

- To modify this form to include all data needed at hiring people
- Training to supervisor about this modified form
- To fix damaged parts in the machine

Note: is not a case to solve a failure in a nasa rocket engine, so
take this consideration, LOL


Please share your thoughts on this.

Thanks

 

Thanks Jennnifer

I agree with you, is not just to modify forms, additionaly
will be changed a document where is described the hiring process.

 

Well, in the hiring process is where is possible to ensure people have the competency , how? , describing in details in procedures , the steps and any other data which can help on it.

 

Yes, but they are very general, we found a "hole" on this, some of the aspects were absent in the reference list.

 

Firstly, unless there is another company in the same town doing exactly what you are doing with the same machines and the same methods you ain't going to recruit a ready made operator off the street. So there is not much point in trying to tighten your recruitment policies, you will end up with either a lack of candidates or broken policies.

And anyway if you had the perfect operator could this still have happened? If the answer is "yes or maybe" (and I think it might be), then you have not found the root cause.

Also you need to frame the problem better: is the issue made a defective part, or is it made a defective part and sent it down the line, or didn't set up the machine properly and made a defective part,........ etc? the root cause may be slightly different depending on what exact thing you are trying to prevent.

At the moment it sounds like; the operator and supervisor both need training, there is a lack of inspection and maintenance of the equipment, a lack of supervision or checking of setups, probably insufficient detail in the work instructions. I think that some new procedures and check lists for introducing new operators and training them up, checking the first 100(?) setups are going to be needed and inspections of the damaged parts (they weren't still on the machine because there were no spares were they? check that contributory cause), probably update instructions for this and other similar jobs. but the rot cause is probably a lack of ownership and leadership if I'm honest

 

I take your point:

I am a metallurgist and I manage a foundry in a small town in China, "talent" and experience of the industry is thin on the ground. When I was in Sheffield you could poach a melter, chemist, process engineer, ops director, whatever from a company doing similar things for similar customers the awareness was valuable but the company's way of doing things still had to be trained and explained. Here I had to start from scratch with the people I could find one of my melters was a takeaway driver another a farmer, one of my finishing operators used to sell water filters and my trainee quality engineer used to be a receptionist in an estate agent shop. They had no baggage and were willing to learn and with training its all worked out, we have had very positive feedback from third party auditors about their professionalism and competence. I don't know how much better it would be here if there was a pool of experienced people I could recruit from, maybe we could have moved a bit faster. But since we could not focus on qualifications we had to focus on the personality and attitude of the candidates and it turns out that is the most important thing.

On the other hand no matter how willing or experienced you can't just take a person and dump them in front of a machine in the expectation they can do the job in the way you want them to. I don't know for sure if this is the culture in the OP's company but reading the post suggests to me that everything is being laid on HR and recruitment like the perfect person for every role is out there and if you can find them then they'll just slot in and get to work like a piece in a machine. From that I infer that training and integration is not given much priority. Certainly something I would reflect on if worked there.

 

One root cause or several ?

Why do you need to force yourself in identifying a single root cause? Problems happened due to "corroborating" factors. Analyze the immediate and underlying causes then select from them those that significantly contributed to the end-problem. Take actions afterwards. Problems will be better solved if solvers refrain from pursuing a single root cause.