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As promised, I’m going to share one of my favourite example root cause analysis stories with you.  I’m not going to include specific details (to protect the innocent), but I think we can all learn from sharing these stories with each other. We would all love to hear your favourite root cause analysis story too, so if you would share it – we’d be very pleased to hear it.  Just leave out names, dates, companies etc, so it’s generic enough to share without causing any upset! Just add your story to comments section below, don’t worry nobody else will see your email address and you can use a made up name or avatar, so we don’t know who you are! So, snuggle up and I’ll start my story…

 

 

 

Once upon a time there was a company that made fruit cakes…

These fruit cakes had a serious following, those that loved them, bought them week in, week out. Life would just not be the same without them. One day, one of the customers faithfully bought their fruit cake as usual, but had to make a complaint that they tasted salty. The company that made them didn’t understand this, and thought maybe this was a ‘one off’ complaint.  Then, the next day, another customer complained that they were salty.  Then another and another, and before they knew it, there was a huge trend of salty complaints.

The team at the company scratched their heads and launched a full-scale investigation, to see what was going wrong. So they checked the specification, the recipe being used in the factory, the process, they re-calibrated the weighing up equipment.  They even checked the supplier of the salt, to see if anything had changed. Everything was fine, just as it should be.

But the complaints continued to pour in…

The lovers of these cakes were getting really upset and the company worried that it would start to affect sales.  They even considered stopping production all together until they could work out what was wrong. So, they sent in someone to try and find out what was wrong.  Let’s call them ‘The Detective.’ The Detective arrived at site and armed with the product specification, they started to check everything in minute detail.

First stop, the recipe.  They cross-checked the specification recipe with the recipe being used in the factory.  The factory recipe matched exactly to the spec. They checked the weigh up sheets to see if they matched and they did.  The recipe was being weighed up manually, and the exact weights that were being weighed up were being manually recorded, as the automatic recording system had been stolen a few weeks previously.  So, they could see the exact amount that went into every batch and they could see that it matched the spec.  They even watched batches of the product for that day being weighed up to make sure they were exact and then watched them being processed, to make sure there was nothing going wrong.

As the batches were being processed, The Detective checked all of the processing settings and the process ingredients to make sure there was nothing that could have caused the product to taste salty.  Everything was just as it should be. They checked the scales and the weigh cells, everything was fine. They checked the ingredients to see if any of them had changed; nothing!

They carried out a taste panel of the batches that were made that day, as they knew they’d been weighed up and processed exactly as they should be.  Although The Detective could taste a slightly salty flavour, they knew that the product was as it should be – so why did it taste salty?

The Detective couldn’t come up with the answer and so, at the end of the day, had to go back to their hotel. Sitting in their hotel room, baffled, The Detective thought – I can’t go back to my boss and say I can’t find the answer.  Something was bothering them too.  Something that someone had said that day about the theft. They got back in the car and went back to the factory.

On arriving at the factory, they asked the team to explain a little more about the theft.  The stores had been broken into and some of the computer equipment had been stolen.  What computer equipment? The weighing scales system they said. What did the weighing scales system do?  It held the recipe and logged the weights, each time a recipe was weighed out.  Were these weights from each batch weighed, printed off the The Detective said?  No, they were just held in the system said the team. Ok, so how was the recipe uploaded to the system?  It was done by the stores supervisor.  Ok, so how was the recipe given to them to upload?  Do you have any previous examples of the recipes that were uploaded?  The stores team looked back through all their old paperwork in their filing cabinets and through their old dairies.  After searching through a lot of paperwork, we found a recipe that had been given to them, written by hand, many, many years previously ready for the launch of the product.  This was the recipe that had been put into the weighing up system and had been used for years since it launched.  And guess what?  The hand written recipe didn’t have salt in it; it had been missed off by accident.

So, when the system was stolen, they went back to the spec and put the right recipe back in, not knowing that this would cause a problem. The loyal customers were used to the product without salt in it and when the salt was added, it tasted salty to them. The salt was removed and the customers were happy again.

And, the moral of the story?  Well, there are many…

I’ve given you the root cause of the problem.  The corrective action was to take the salt out of the recipe and amend the artwork for the packaging to suit. But, there are so many preventive actions that can be applied to this problem. Can you help to provide your thoughts on what they should be, to ensure that it fixes the root cause once and for all?
Please, add your stories too!  We’d all love to hear them.   Next time, I’m going to write about my thoughts on what I call a pre-emptive mindset, which I think is really aligned to root cause analysis – as it’s aim it to prevent problems rather than wait for them to happen…something we would all like to do!

3 Comments

  • Adele says:

    Hi Kassy – that’s a really good story. A great example of how we need to look beyond the immediately obvious potential causes, once these have been eliminated to then keep digging. There’s a bit of gut instinct needed too – it’s real detective stuff.
    Thanks
    Adele

  • Anne says:

    Hi Kassy, my first thought was using salt in place of sugar.
    So, preventative actions: keep a master list of all recipes at main company where store can pull recipe versions from the master. Some (non-electronic) folks quality departments also keep latest version as a hard copy in a “master book”.
    Then, monitor this recipe by have two managers initial actual recipe (2 sets of eye) for a predetermined time.
    Keep records of occurances; without these older recipes this amazing fruitcake recipe could have been gone forever.
    Best,
    Anne

  • Audrey says:

    Hi Kassy,

    Like Anne, my first thought was that somehow (from supplier or within the stores) the salt and sugar had got mixed up and salt was being used instead.
    To prevent just following one lead and ensure that all angles are covered (as I have learnt through my career that it can be more that one change/error that can lead to an incident that requires investigating), I like to use the 6 M fishbone to carry out Root Cause analysis. It builds in the discipline during investigations to look at all aspects and can be used with 5 whys and a multidiscilplinary team (as big or as small as is requred), or on a smaller scale to help gather information from all sources and then all the facts are to hand.

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