5 Why's Help Needed

Need to help with my 5 why's. Does this look okay? Any help is appreciated.

Problem: The ENG0002 Form, Rev. D does not include a *BPR review number and is designated as N/A; additional investigation revealed that no proof of a BPR review was conducted is on file.

WHY1: Without completing the BPR review process, the document was released to All Business Processes (our main procedure library).

WHY2: There was no peer review to ensure that the document had completed the BPR process.

WHY3: The staff (responsible doc control staff) was not notified that the document had been uploaded to All Business Processes.

WHY4: Staff are not required to complete document peer reviews prior to posting to the library, nor are they set up to receive notifications within SharePoint when a document is posted to the library.

WHY5: DOC0013 (our doc control procedure) does not require that notifications be sent to staff or that a peer review be carried out prior to posting documents to the All Business Processes library.

*BPR is our document control review process. A number is always assigned when a document is submitted for review and approval.

Facts of the situation: 1) person who uploaded the document circumnavigated our process. 2) no one else on our team saw/knew that this person uploaded the document without a BPR number. 3) this issue was not identified and corrected.

 

Hello, Andy. We are obligated to include a 5 Whys as part of our Corrective Action procedure. This is a problem that demands more than just a basic fix. The person who uploaded this document plainly bypassed our document control review and approval process by simply posting it to our library. Our team has all authority to do so. There should be additional steps in our document control process to verify that BPR numbers are included on documents prior to posting. However, this did not occur, and no other members of our team were alerted or were aware of this person avoiding the process and directly posting the document.

 

I agree, but I have to follow our procedure. Thus, I need to finalize my root cause and action plan. Is there anything that pops out to you that I should clarify in my 5 whys?

 

I think we need to add a requirement within our document control procedure that 1) automated alert notifications be sent when a document is posted within SharePoint 2) a requirement for peer review of a document, where two parties sign off after completing our grammar, format, and information review checklist 3) Add a column to our document log to include a BPR number and Revision (this is an internal log my team uses) 4) provide training to staff to not post without going through BPR. What do you think?

 

Thank you, I appreciate the feedback and help, Andy.

 

Andy, is the following clearer...?

Problem Statement:

ENG0002 Form G, Rev. D, does not show a BPR review number as required by DOC0013.

5 Why’s

WHY? The BPR review and approval process was not completed.

WHY? A new BPR form was never submitted for the document to initiate the BPR process.

WHY? A staff member bypassed the BPR process and posted the document directly to All Business Processes.

WHY? There was no secondary peer review to confirm that the BPR process was followed, as evidenced by the existence of a BPR form record and number. Additionally, there were no backup SharePoint alerts sent to other staff informing them that a document had been posted to All Business Processes.

WHY? (root cause) In DOC0013, there is no requirement for a secondary review by another person prior to uploading a document to All Business Processes, nor is there any requirement for alerts to be delivered to staff when a document is posted or changes are made to All Business Processes.