Deep dive into root cause analysis…
With less than 2 months to go, to Issue 8 being released – I’m going to start covering some of the new topics that were highlighted in the draft version of the standard, that will very likely be present in the standard when it’s published in August. If you didn’t get the key changes download in our last issue 2 weeks ago, just click on the image to the left. All you need to do is sign up to Smart Knowledge and access it through our downloads page in your welcome email.
One of the topics that was enforced in Issue 7, is being reiterated again in Issue 8 and it seems to be a popular topic with our Technie’s (subscribers) too, so I thought I’d tackle this first – root cause analysis…
BRC Issue 7 Root Cause Analysis Sections
1.1.3 Senior management review: It is the senior managements responsibility to ensure that actions arising from the review, or actions reviewed as part of the KPI review, must be resolved to root cause.
1.1.5 Resources: Where effective implementation of the QMS and Food Safety Plan is not being applied, and the root cause is due to a lack of resource, the auditor can apply an NCN.
1.1.10 Recurring NCNs: The senior management must ensure that root cause preventive actions of the last BRC audits NCN’s have been effectively implemented, to ensure that the same NCN’s do not apply on subsequent audits.
3.7.2 Management of NCN’s (part of Corrective & Preventive Action): All NCN’s raised must be assessed for their root cause and preventive actions applied.
3.10.2 Trending of complaints: Where a trend of complaints is highlighted root cause preventive actions must be applied.
In Issue 8, Root Cause Analysis has also been applied to the following areas…
3.8.1 Non-conforming product: Where non-conforming product is produced, root cause analysis should be used to apply preventive actions.
3.11.2 Withdrawal and recall procedure: Must now include a process for applying root cause analysis to avoid future incidents.
In order to be able to apply root cause analysis effectively, we need to understand firstly what we mean by root cause ,and also what the difference is between corrective action and preventive action.
BRC define ‘root cause’ to be “The underlying cause of a problem, which, if adequately addressed, will prevent a recurrence of that problem.” So basically, if something goes wrong you can normally quite easily see or understand why it went wrong. Let’s take an easy example; a mixing bowl of product, with bits of green scouring pad in it.
- What went wrong? Well the green scouring pad clearly fell into the mixer – simple!
- How do we correct the problem? We throw away the mixing bowl of product.
- How would we correct the problem if we were to see the green scouring pad on top of the mixer, while in production? Well, we’d pick up the green scouring pad and throw it in the bin.
These are corrections to the immediate problem that faces you. Therefore, we call these corrective actions. The difference between this and preventive actions – is we need to think about why the problem occurred in the first place. Establishing the real why, is the root cause analysis part.
So, let’s go back to the green scouring pad…
You may have heard of the root cause analysis system – called the 5 why’s. It doesn’t necessarily have to be ‘5’ why’s, but apparently someone somewhere once decided it takes asking ‘why’ 5 times, to get to the real root cause of the problem. Don’t get hung up on the ‘5’ for now, just think about the theory of asking why.
So, why did the green scowering pad get into the mixer of product? Well, someone left it on top of the mixer.
So, we then ask – why did someone leave it on top of the mixer? The answer to this could be numerous, but it will probably be something like – they were not trained to know that they must collect all the cleaning equipment before leaving the job. Or it could be as simple as they were tired at the end of their shift at 6 am and forgot to take it with them. Let’s go with that for now, as human error can only be expected, we are human after all.
So, if it was a mistake – what do we do about that? Well let’s ask why again. Why did they forget to take it with them? Again, the answer could be numerous and perhaps not clear at first. We have to think about this practically and not be defensive or critical. If you were tired, having worked a night shift – do you think you could leave a green scouring pad on the top of the mixer by mistake? If we’re honest, we all could. Even if we realised what we’d done when we were in the changing rooms to go home, would you really go back and retrieve it? Probably not.
So, the real value in root cause analysis is establishing a solution to prevent the issue happening again…
What would prevent the person from forgetting?
What can we do to help them not to forget?
What can we do if they were to forget, to prevent it getting into the product?
Well we could:
- Put in place a system for checking out and checking in the cleaning equipment
- We could ensure that cleaning is verified at the end of the shift, to make sure that all the cleaning equipment has been removed
- We could include checking for removal of cleaning equipment in the production start-up checks
- We could retro-fit a lid on the mixing bowl, so things couldn’t fall in
- Have an alternative cleaning tool, such as a brush attached to a chain by the mixer, so it can’t fall in
- Or even – if you really went for it – install a CIP cleaning system for the mixer, so manual cleaning with green scouring pads wouldn’t be needed at all!
These are all preventive actions, which would all prevent the issue occurring again.
One of the parts of our QMS systems that I hear fails regularly is internal auditing. I’ve been asked a number of times, how to fix this and if there is an alternative way of carrying out internal audits that works better. I think this would be a really good topic to put through root cause analysis, so I’m going to cover that next time.
Time to share…
If you have any other elements of your system that continually cause you problems or fail, it would be great if you could let me know them and we’ll use them as a topic to write about. Add them to the comments section below, don’t add your name if you want to stay anonymous (your email won’t be visible to others). Over the years I’ve seen many problems arise and have a few interesting stories that we could all learn from. One of which was about a trend in complaints that we struggled to solve. It’s a really unique story of root cause analysis, which I’ll share with you. Again, if you’ve resolved any problems to root cause that you would share with us, we’d all be really pleased to hear them. Please remove any information to protect the source, so we don’t know where they came from – it’s the story that we can learn from, not the specifics of who it was about. And, again, remember to not put your name – think of a quirky avatar name instead!