Root Cause Analysis – what happens when a problem affects multiple standards?
Let’s presume that you are working a problem in your facility – the problem is a rather thorny one, and is affecting multiple management standards. How should you handle the root cause determination, and the corrective action resulting from it? For reporting purposes, how do you report it for metrics – as a problem in all three metrics? Do you pick one and let the other standard metrics alone? What’s the best way to handle this?
Here’s a hypothetical problem: you’ve noticed that a chemical used in your facility has been used up prematurely, so there is insufficient quantities to maintain production; you investigate further and discover that an employee was trying to attach a hose without the correct safety equipment and process equipment in place, and he was injured; before he could turn off the valve, the chemical poured out onto the tank farm floor, resulting in a chemical spill. The resulting problem affects the product quality, employee safety and health, and requires a chemical spill cleanup – so we’ve got an impact from a QMS, OHS, and EMS standpoint. What’s the best way to handle the root cause determination, and the interim and final corrective action(CA) ?
Our first step is the put an interim CA in place to ’stop the bleeding’. Our first concern is the employee – let’s make sure that they’re safe and getting the attention they need. Ensure that all safety precautions are in place, then institute chemical spill cleanup per your environmental procedures and following manufacturer and MSDS recommendation, paying particular attention to containment and prevention of chemical down drains that lead to water supplies, or out the door and to the soil. Now that we’ve got the basics covered in the short term, we want to focus on a) understanding why this happened, and b) ensuring that this won’t happen again. In order to do that ’smartly’, we want to assemble a small team from the major groups affected, to step through a formal corrective action process — determine the root cause — in this case, determine how the spill happened in the first place. The team should also determine what permanent CA will be implemented, and take steps to put the permanent CA in motion (ordering new supplies, reviewing spill procedures, safety procedures, etc. and determining what will ensure that this problem won’t happen again, for this reason). Finally, the org should determine what steps need to be taken to prevent this in the future (preventing this from happening for other reasons), and what this impact may have to product quality. Do customers need to be notified that shipments may be delayed? Can an expedited shipment of the chemical be ordered and delivered?
Now let’s take a minute to go back and review:
- Quality is affected – shortfall of one of the raw materials
Fix: investigate expedited delivery
- improper handling resulted in a chemical spill – both environmental and occupational health and safety implications
Fix: review the existing environmental and safety procedures; update as required;
- Preventive action: how could a spill have happened if not this way? How could an employee have been injured if not this way? How could our product quality have been affected if not this way?
Is there anything we’ve forgotten? Anything you’d do differently? Let me know – I’d love to hear your comments!
