Scenario 1 Five Whys

Scenario 1 Five Whys

Someone examining bottles on a line

Using the example of an incorrectly weighed ingredient and the tools described, a Five Whys study has been performed on one of the lines of investigation / ideas generated from the earlier scenarios.

Identify the direct causes and actions leading up to the incident – keep asking 'Why?'. Remember that there isn’t ALWAYS 5 Whys. Sometimes there are 3, there could be 5,6 or 7, but you just have to keep going until you can’t ask 'WHY?' any more.

WHY did the operator make the error?

Operator unfamiliar with procedure.

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WHY was the operator unfamiliar with the procedure?

Operator was trained but no supervision or sign off to confirm that training was satisfactory.

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WHY was the training not satisfactory?

Both ingredients look identical and were not labelled.

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WHY were ingredients not labelled?

Labels were removed during last clean and not replaced.

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WHY were labels removed and not replaced?

Cleaning staff didn't consider potential for error, and checking labels not part of anyone's duties.