Many organizations experience repeated occurrences of the same type of undesired incidents and nonconformity (hereafter referred to as ‘errors’) damaging to employee health and safety, the environment and customer satisfaction.
The key to gradually breaking down this pattern can be found in the identification of root causes to such errors (being human error or malfunctioning equipment) and the subsequent elimination of such root causes – the corrective action. For such purpose, two processes are needed:
- Reporting, categorization and root cause investigation of incidents and nonconformity
- Launching of corrective action and their effective follow up
In order to succeed, it is essential that:
- Top management recognizes that everybody makes mistakes or contribute to error generation through any lacking structures, standards or behavioural cultures
- Errors are consistently reported, categorized and analysed from all levels of the organization and not just from the factory floor or frontline. It will be a significant advantage to discover, report and treat errors as early as possible before they generate real hazards
- Managers are engaged across the organization for the purpose of agreeing on corrective action and ensuring their effective implementation in a structured process
- Top management ensures that these processes are undertaken efficiently which among other require a certain amount of trust and humility and that managers and staff are held accountable for their errors and corrective action
There are many techniques available for root cause investigation. The method is in principle indifferent as long as the true root cause(s) and any contributory factors (especially human factors) are identified.
Customer complaints and internally reported near miss can provide significant insight into the organization’s lacking structures and standards.