Thought shower pitfalls
In Scenario 2 (Bars of chocolate containing hazelnuts have been incorrectly packaged in 'nut-free' plain chocolate wrappers resulting in a possible health risk to anyone with an allergy or intolerance to almond and other nut), a cause for further investigation may be identified.
Question: Why has this incident happened?
Answer: The wrong packaging has been used to wrap the product.
Therefore a conclusion could be drawn that the most probable cause of the incident is that systems for the control of packaging have broken down. This must be explored, while not ignoring other potential causes.
This may be a cause, but it is not a root cause. A cause is merely a line of investigation or questioning, while a root cause is the answer.
Also, it can be easy to follow the most simple and straightforward path to the most obvious answer. While this may turn out to be correct, it must be ensured that nothing is dismissed prior to the use of further tools.
Examples of other factors or possible causes for this incident could be:
- The packaging (and controls) are correct, but the product inside is the wrong one
- Wilful contamination or adulteration by staff
- False or inaccurate complaint or description of incident
Generalised Root Cause recommendations and solutions such as ‘…remind the operator to pay more attention…’suggest that:
- The basic causes of the incident have not been identified
- Further work may be required to determine the real underlying causes of why the incident occurred – insufficient RCA tools and techniques have been used
- The most effective solution(s) to the problem has not yet been identified