Procedure not followed

Hopefully you can relate to this scenario: A problem occurs at work, a person or persons complete a root cause analysis, their finding is “The procedure was not followed”. Have you seen this? As Lean Six Sigma professionals we must challenge organizational leaders to recognize “Procedure not followed” is not the root cause, rather it is the beginning of the root cause analysis.
The primary issues with “procedure not followed” as the root cause are:
  • We are saying the person is the root cause
  • Limiting corrective actions to some form of discipline or training
  • We do not thoroughly analyze the procedure
  • We are assuming procedure is flawless
As problem solvers we aim to find the root cause so a countermeasure (solution) can be put in place to prevent that specific problem from re-occurring. To reach this higher level of problem solving requires a few key understandings:
  1. Work is a process that can be mapped, analyzed, and improved
  2. Humans make errors
  3. Errors do not become defects if caught at the error stage
  4. Lasting improvements only occur when solutions are implemented into the procedure, process, or system.
The next time a problem occurs try to focus attention towards the procedure. This is accomplished by asking better questions. Avoid asking “Who did this?”, rather ask:
  • “What is the procedure?”, then
  • “What step in the procedure did the problem originate from?” then
  • “What conditions existed at the time?” more questions until ultimately
  • “What we can put in place to prevent this problem from happening again?”.
“Procedure not followed” triggers this series of questions. Asking better questions is the essence of effective root cause analysis.
Real world example: Employee at brewery turns a valve in wrong direction breaking it, thousands of gallons of product (beer) is lost with 10 hours of clean up and minor injury to employee. Corrective action: Employee is fired.
Problem solved?
See you in class, Erik
“If you can’t describe what you are doing as a process, you don’t know what you’re doing.”
W. Edwards Deming