Читать книгу Root Cause Failure Analysis - Trinath Sahoo - Страница 58

When the problem and root cause is not immediately apparent When you want to prevent the problem from occurring in the future.

Ask yourself, “Will implementing the Systemic Corrective Action prevent the next failure?” If the answer is “NO,” you must understand the deeper WHY.

If human error is identified, you must understand why the human committed the error. What management controlled factor impacted performance? What system must change to eliminate (or significantly reduce) the chance for error? “Training the Operator” is rarely the best response.

Why was the operator not trained properly? Why was the training not effective? What environmental factors caused the operator to not do his/her best work? Did he/she have to go around the system due to other issues or pressures? Can the system be error‐proofed? All root cause analysis must include a look at the associated Management Systems For virtually every incident, some improvement(s) in the Management Systems could have prevented most (or all) of the contributing events – ASQ estimates 82–86% Correct the process that created the problems.

During the 5 Why analysis, you should ask yourself if there are similar situations that need to be evaluated perform a “Look Across” the organization. If this situation could apply to multiple funds, then the corrective action must address all funds.