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Miriam Boudreaux

Lean

Five Signs Your Company Is in Dire Need of Root Cause Analysis and Corrective Action Training

Stop fighting the auditors and get back to basics

Published: Tuesday, January 7, 2020 - 13:03

If you are wondering whether your organization could benefit from formal root cause analysis (RCA) and corrective action training, read on to see if any of these issues are present in your day-to-day operations. RCA and corrective actions are some of the most useful tools for continual improvement.

Here’s why you should include them among your company’s (and all employees’) tool set.

1. High number of NCRs in your company

It’s true that the number of nonconformance reports (NCRs) will depend on the volume of operations a specific company has. Therefore, the “number” of NCRs is a relative figure. However, if you know you have a high number of NCRs, the issue may be that you are not performing effective RCA and corrective action.

When you issue an NCR, you are doing it to track and quantify the nonconformances, defects, or issues causing your production or service operations to lag. But the story should not end there. The biggest benefit of tracking NCRs is the ability to see how your operation’s performance is changing from week to week, month to month, and from product to product. Tracking allows you to use that information to select which issues you want to concentrate on, in order to perform corrective action and subsequently RCA.

Is the number of NCRs in your company high? You may want to tabulate your NCR data weekly, select which issues to focus on, and do an RCA. By doing a thorough RCA and corrective action on the critical few, you can start a concerted effort to drive down the level of NCRs. Remember: Tracking for the sake of tracking—with no clear process to drive this number down—is a clear indication that you are not following up with corrective action as needed.

2. The same mistakes keep happening over and over

If corrective actions span from similar sources or mistakes, there is a very good chance they are not being addressed appropriately to begin with. This may mean that the RCA conducted for any particular issue:
• Is flawed
• Is not thorough enough
• Is not getting to the actual root cause
• Implemented actions do not address the root causes identified 

I frequently say, “Make new mistakes, not the same mistakes,” because repeating the same mistakes is a good indication that the RCA conducted on the initial mistake was not robust enough to prevent the same problem from happening again.

3. Nonconformances from your internal or external audit can’t be closed

Conducting a comprehensive corrective action is not just about finding the root causes of a problem. It also entails identifying the actions to address the very root causes identified, and of course being able to document all of these in a coherent manner. Often, the responses can’t be understood, or they don’t represent the truth because they are being sugarcoated.

From the moment you write the problem statement, you need to keep in mind that it should make sense to people who were present during the audit, as well as those who were not. It should also make sense now, as well as six months from now, when the issue is no longer fresh in everyone’s minds. Above all, write the truth.

I can’t recall how many times I have read a corrective action and RCA, and then followed up with the person who wrote it only to get a totally different explanation. The excuse is always, “I didn’t think I needed to include that.” This is an immediate red flag that employees are not properly trained in RCA techniques. That’s why at Mireaux all of our turnkey consulting projects make RCA training a mandatory step.

4. Minor nonconformances from your internal or external audit keep getting elevated to majors

Another scenario to consider:
• A minor nonconformity from an audit is accepted.
• The problem happens again.
• The minor nonconformity is elevated to a major one upon verification at a subsequent audit.

In the case described above, there is a high probability your root causes or actions were flawed, not carried out as planned, or poorly implemented. An auditor expects that, with proper RCA and corrective action, a problem should not happen again unless it’s due to totally different circumstances. So if it does, then your minor nonconformity gets elevated to a major nonconformity.

5. Your ISO or API certification gets revoked

If your company’s certification to standards such as those developed by the International Organization for Standardization (ISO) or the American Petroleum Institute (API) get pulled or revoked for issues other than financial, you may have serious RCA and corrective action shortcomings. To get to this stage, it means that you were issued nonconformances that were either not answered, answered poorly, or repeated during the audit follow-up. And this cycle would have had to repeat for a few months for the registrar or API to finally decide to go this extreme route.

If you were part of this process, then you know whether your corrective actions were rejected, or whether the problems resurfaced during follow-up audits thus invalidating the RCA. However, if you were not part of this process, and you have no idea why you lost the certificate, be aware that some management representatives may hide all of these from top management with the belief that the issues will eventually resolve themselves. If you find yourself with this dilemma, please understand these issues will not be resolved until you conduct thorough RCA, while also accepting that you may need to overhaul many of your processes.

One more for API certification holders

6. You engage in a never-ending electronic fistfight with API regarding nonconformances

If you are in the middle of a back and forth with API’s assigned audit reviewer, and findings are not getting closed, stop! Put the mouse down, and take a deep breath. A shotgun approach will not work with API.

API’s reviews of your company’s responses to audit findings are conducted by employees who are well-trained in RCA techniques and corrective action principles—but who weren’t present during the audit. Your RCA, corrective action responses, and supporting material must be robust enough to withstand this process. If you think the issues will resolve themselves and the auditor will eventually get tired and just accept your responses, you are wrong.

Go back to the basics, assemble your team of all appropriate stakeholders, and use RCA techniques such as 5 Whys to find the root causes of the problem. Enlist the same stakeholders to implement various action items to address the root causes found. Once all actions have been implemented and verified, submit your responses to API in an organized fashion.

Discuss

About The Author

Miriam Boudreaux’s picture

Miriam Boudreaux

Miriam Boudreaux is the CEO and founder of Mireaux Management Solutions, a technology and consulting firm headquartered in Houston, Texas. Mireaux’s products and services encompass international standards ISO and API consulting, training, auditing, document control and implementation of Web QMS software platform. Mireaux’s 6,500 square foot headquarters, located in the northwest area of Houston, houses their main offices as well as their state-of-the art training center. Mireaux itself is certified to ISO 9001:2015 and ISO 27001:2013. To get in touch with Miriam Boudreaux, please contact her at info@mireauxms.com.

Comments

This article addresses the biggest source of audit findings.

BSI (2019) cited clause 10.2.1 as the greatest source of major IATF 16949 findings, and IATF 16949 clause 10.2.3 (problem solving) as the second greatest source; 10.2.3 is related directly to CAPA. These add up to about 34% (1/3) of the major nonconformances. (Brown, Robert. 2019. "Beyond the IATF Transition: Analysis of Non-Conformities and Next Steps" (BSI webinar, January 22 2019)).

My own position is that, because so many other processes of the quality management system (ranging from customer complaints and audit findings to outputs of the management review meeting) depends on CAPA, inadequate CAPA and root cause analysis could well be the biggest source of findings across the board. This makes this article on root cause analysis and CAPA training particularly worth reading.

I would even take it a step further by adding that CAPA can be used on all seven Toyota production system wastes and not just poor quality, if we treat a gap between the current state and a desirable or possible future state as a "nonconformance." This could be a gap as identified in an energy review (ISO 50001). 

AIAG's Effective Problem Solving (CQI-20) cites three root causes. The traditional occurrence root cause is why the problem happened. The escape root cause is why it reached the next process (if it did), and the systemic root cause is why the planning process failed to prevent it. This ties in with FMEA where the prevention controls seek to disable the occurrence root cause of the failure mode, while the detection controls seek to intercept any poor quality that is created before it can reach the next process.

As you point out, "If corrective actions span from similar sources or mistakes, there is a very good chance they are not being addressed appropriately to begin with." This could mean that corrective action taken in one part of the organization is not deployed to similar activities elsewhere (read across/replicate process); Henry Ford once wrote that the benefit of our experience cannot be thrown away.