RCA Speaker Notes PDF

Introduction to Problem-Solving with Root Cause Analysis Manufacturing Excellence, HSE 2024 Read out load Good morning/afternoon/evening everyone, I want to thank you all for attending this session. My name is (insert your name here) and I am the (insert your title here). Today, I will be...

Introduction to Problem-Solving with Root Cause Analysis Manufacturing Excellence, HSE 2024 Read out load Good morning/afternoon/evening everyone, I want to thank you all for attending this session. My name is (insert your name here) and I am the (insert your title here). Today, I will be presenting the Introduction to Problem-Solving with Root Cause Analysis. 1  Course Objectives Upon completion of this course, participants should be able to: DESCRIBE THE COMPONENTS OF A RECOGNIZE THE BENEFITS/PITFALLS APPLY PROBLEM-SOLVING FACILITATE COLLABORATIVE RCA ROOT CAUSE ANALYSIS. OF PROPER ROOT CAUSE ANALYSIS PRINCIPLES USING THE 5-WHYS AND SESSIONS TO CREATE HIGH-FIDELITY AND WHEN TO USE IT FISHBONE METHODS CORRECTIVE ACTIONS THAT FIX SYSTEM ISSUES Upon completion of this course, participants will be able to:  Describe the components of a root cause analysis.  Recognize the benefits/pitfalls of proper root cause analysis  Apply the problem-solving processing using the 5Whys and fishbone methods  Facilitate collaborative RCA sessions 3. 4. 2  5. 2  Course Content Introduction to Problem-Solving – Definitions of Problem, Symptoms, Root Cause, Root Cause Analysis (RCA), Corrective Actions – RCA process overview – Benefits/Pitfalls of RCA Fundamentals of Problem-Solving – Overview of 8-step problem- solving process – 5 W’s and 2 H’s approach – Common problem-solving tools – Components of a 5Why & Fishbone RCA – Hands-on exercises/Case Studies SAY: In today’s class, we will review the definition of root cause, the benefits of performing root cause analysis, review a recommended problem-solving process that contains the root cause analysis step, provide examples of problems addressed to root cause, things to keep in mind when performing this analysis. 3  3/11/2024 SAY: Before we jump into the content, let’s take a look at this short clip from the 1995 movie Apollo 13 – based on the events of the seventh crewed mission in the Apollo space program and the third meant to land on the Moon. PLAY THE CLIP. (4:11 minutes) ASK: Anyone familiar with this mission or the movie? What was the problem? EXPLAIN: The phrase, “Houston, we have a problem,” has been informally used to describe the emergence of an unforeseen problem. Link to Full Apollo 13 scene: https://youtu.be/fgvC-1TZP9E 4  Problem… What Problem? Definition of a Problem: A matter or situation regarded as unwelcome or harmful and needing to be dealt with and overcome. “A thing that is difficult to deal with or understand.” – Oxford Learner’s Dictionary A gap between what is desired and what is happening. ASK: What is a problem? 5  What’s In Manufacturing/Operational the Environments: Problem? A problem is when an event occurs that is considered out of the norm and has a negative result. Examples: Safety – an incident/injury Quality – product defects/non-conformance Delivery – missing deadline/target Cost – spending over set operational budgets EXPLAIN: In a workplace, a problem is when an event occurs that is considered out of the norm and has a negative result. These could be safety-based, production or process-based, Failure-based (engineering/maintenance related), or systems-based (related to change/risk management. ASK: What are some problems you have to deal with in your day-to-day? (Optional) DO: Have a participant write down the class's response on a whiteboard or clip chart. (~5 minutes) 6  Digging for the Root Cause Root Cause An initiating cause of either a condition or a casual chain that leads to an outcome or effect of interest. ASK: What is a root cause? SAY: Essentially, a root cause is the basic cause of something. In some situations, there may be more than one root cause. Defined in other ways: The causal or contributing factors that, if corrected, would prevent recurrence of the identified problem The “factor” that caused a problem or defect and should be permanently eliminated through process improvement The factor that sets in motion the cause-and-effect chain that creates a problem The “true” reason that contributed to the creation of a problem, defect or nonconformance 7  Digging for the Root Cause I need that fixed now! Symptom Result or outcome of the problem What you see as the problem (Obvious) Problem Gap from goal or standard Root Cause System below the surface, bringing about the problem (Not Obvious) EXPLAIN: Being able to define the problem, the symptoms, and any potential outcomes, sets the foundation on how the analysis is going to go. Remember the problem is the gap between what is desired and what is currently happening. The symptom is the obvious result of a problem. But when digging for a root cause, you must look below the surface to understand what is bringing about the problem. This may not always be the most obvious answer. Often, we focus too much on fixing the symptoms of a problem – so the problem may reoccur again and again. 8  Digging for the Root Cause Symptom Car won’t start PROBLEM Problem Dead Battery Root Cause Did not turn off lights EXAMPLE: Let’s say you leave out the house in the morning to go to work but your car won’t start. You realize that your battery is dead. Then you remember you forgot to the off the vehicle lights when you last drove the car. ASK: What was the symptom? What was the problem? What was the root cause? 9  What is Root Cause Analysis? Error Recognition Information Review Investigation Corrective Action Validation Defining and Validating that the Identifying a problem. Containing and analyzing Defining the root corrective action implementing the actions the problem. cause. prevented required to eliminate the root cause. recurrence of problem.. SAY: As the name suggests, root cause analysis is a set of problem-solving techniques and tools that offers teams an opportunity to identify the root causes of problems they’re facing. But root cause analysis involves more than just identifying the root cause of a problem. It also helps teams identify contributing factors, prepare corrective actions, and improve business processes through continuous improvement. EXPLAIN: Root cause analysis is part of a complete corrective action process. Getting to root cause is only half the battle. Preventing the root cause requires many more additional steps. RCA is used in many areas but especially in evaluating issues dealing with Health and Safety, production areas, process manufacturing, technical failure analysis and operations management. While each area has differing methods, a logical process flow applies to all. 10  How does it differ from what we do now? USUAL APPROACH PREFERRED APPROACH EXPLAIN: In most companies, when a problem surfaces, we firefight and try to put out the “fire” immediately. This involves some kind of quick fix or work around to keep the process moving. Just as we find an acceptable “band aid” fix that works, another “fire” starts in another area/place/process, and we rush to fix it. Here is our usual approach to problem-solving. We never take the time to revisit these “fires” to figure out why they happened in the first place. We keep dealing with the same problems over and over again. EXPLAIN: The preferred approach is similar. First, we develop a quick fix for the problem. However, instead of rushing to the next issue of the day, we take some extra time to do root cause analysis so that same problem is not tomorrow’s big “fire.” We then implement the necessary change(s) and check to see that is does not return. Lastly, we scale the solution across the site/facility or organization so other areas and groups do not have the same problem as well. 11 ASK: Which one of these approaches do you think will take longer to complete? Obviously, the preferred approach will take much longer, so why should we take the time? We must think in the long term. In six months or a year from now, do we want to be dealing with the same number of problems as we are today, or do we want to have more time available to work on improving the process and other value added activities. 11  Benefits/Pitfalls of RCA ASK: Why do you think organizations/teams do not perform Root Cause Analysis? DO: Write participants responses on whiteboard or flipchart. (5-7 minutes) Disadvantages of RCA Time and effort taking Complex and subjective Potential for blaming culture Difficulty in identifying all factors Implementation challenges Then ASK: Why do you think organizations/teams should perform Root Cause Analysis? 12 DO: Write participants responses on whiteboard or flipchart. (5-7 minutes) Advantages of RCA Enhanced problem solving Prevention of recurrence Improved decision making Enhanced organizational learning Increased customer satisfaction Regulatory compliance Less rework Increased profits SAY: As the VP of Manufacturing once put it, “it seems never have the time to do it right, but we have all the time to do it again”. EXPLAIN: When it comes, to RCA, we must recognize the value of the intangibles (lost profit opportunities, enhanced analytical skills, teamwork, and morale) and their effect on the tangibles (good production, safe work environments, less rework). 12  But Who Is to Blame? Most human errors are due to a process error A sufficiently robust process can eliminate human errors Placing blame does not correct a root cause situation Is training appropriate and adequate? Is documentation available, correct, and clear? Are the right skillsets present? SAY: A “no blame” environment is critical. Focus on the facts and the process, not the people or the personalities. EXPLAIN: The key is to ask why the problem occurred and trace back the causal factors until you reach the root cause. Jumping to conclusions or blaming others based on superficial or incomplete information, derails the RCA and you’d likely see the issue come up again at some point. During the RCA process, collect evidence that can help you understand the problem and its causes, not to justify your opinions or blame others. Be open-minded and curious and seek multiple perspectives and sources of information. Avoid confirmation bias, which is the tendency to look for or interpret information in a way that confirms your pre-existing beliefs or expectations. 13  When should an RCA be performed? SAY: We’ve established that RCA can be time-consuming and often objected for various reasons. ASK: So, when should an RCA be performed? EXPLAIN: An RCA is not advised for every failure or unplanned incident. For failures where effects are minor or non-existent or they are unlikely to reoccur, root cause analysis may not be beneficial. Select a few examples from the word cloud to have participants discuss why a RCA may be appropriate in that specific case. SAY: Failures that are recurring, systemic, and critical are the best fit for the in-depth problem-solving methods used in RCA. When you do not dig deep enough into the detail of these problems, you should expect them to continue to reoccur time and time again. 14 NOTE: The timing for the RCA should be only after the situation is contained (immediate action) and/or personnel are safe. 14  RCA Decision-Making Guidance Work Injuries Near Misses Environmental Illnesses - Serious Medical Treatment -Restricted Work Injury -Potential Irreversible Very Serious -Lost Time -Potential Fatality -Irreversible/Fatality Catastrophic Customer Production/ Maintenance Complaints Process Issues Equipment Failures Plant At-Fault Increase in Scrap Extended Long Start-Ups Downtime 3/11/2024 SAY: You may be still wondering, “How do we know when we need to conduct an RCA”? EXPLAIN: It’s a great question – that may vary based on an organization’s values and other drivers. In certain situations, IPEX has defined when a thorough investigation is necessary. These situations make up a “RCA trigger” - something that can be used to prompt us to conduct an RCA if the outcome of an event breaches a specific threshold. Conversely it also lets us know when we do not have to conduct an RCA based on the event not breaching a specific threshold ASK for other examples. SAY: An RCA trigger, or a set of triggers, can be extremely helpful in making sure we spend the time performing RCAs on the right events and not on the events that have little value to the business. Limits/Threshold 15 parameters should be dynamic in nature and may change over time. SAY: An RCA decision diagram helps to guide you through the various RCA triggers that you have in order to determine if you need to do an RCA or not. 15  Importance of the Root Cause Not knowing the root cause can lead to costly band aids. The Washington Monument was degrading Why? Use of harsh chemicals Why? To clean up after pigeons Why so many pigeons? They eat spiders and there are a lot of spiders at the monument. Why so many spiders? They eat gnats and lots of gnats at the monument. Why so many gnats? They are attracted to the light at dusk. Solution: Turn on the lights later. SAY: To summarize the importance of the root cause, we will review the issue of the Washington Monument. EXPLAIN: Problem: One of the monuments in Washington D.C. was deteriorating. Because harsh chemicals were frequently used to clean off the large number of bird droppings on the monument. the monument. There was many bird droppings on the monument because the population of spiders in and around the monument are a food source to the local birds. There was a large population of spiders in and around the monument because the swarms of insects, on which the spiders feed, are drawn to the monument at dusk. off the large number of bird droppings on the monument. The lighting of the monument in the evening attracted the local insects. Solution: Change how/when the monument is illuminated in the evening to prevent attraction of swarming insects. 16 SUMMARIZE: This story is often used in RCA trainings because it drives home a powerful point: deep understanding of the root causes of our problems yields simpler, more effective, and less costly solutions. 5 Whys Example: The Truth Behind a Monumental Mystery (thekaizone.com) 16  Corrective Actions Immediate action The action taken to quickly fix the impact of the problem, so the “customer” is not further impacted Permanent root cause corrective action The action taken to eliminate the error on the affected process or product Preventive (Systemic) root cause corrective action The action taken to prevent the error from recurring on any process or product EXPLAIN: To do a root cause analysis the right way, you should eventually get to a point where you are defining and implementing the actions required to eliminate the root cause. SAY: There are three types of corrective actions. ASK: What is the difference between the 3 types of actions? EXPLAIN: Immediate is the action done to “stop the bleeding” Permanent is typically done on a specific area or product to prevent the root cause from recurring. This is where many companies stop. Preventive is changing the process so that problem does not reoccur again in that area, or any other area in the future. This forces departments and groups to break down walls and communicate for the good of the company. 17  Examples of Corrective Actions All current batch Form changed to Similar forms with of paperwork re- mandate same fields used inspected by completion of all over in another worker certain fields company are for same type of changed to problem “mandatory” Immediate Permanent Preventive If preventive not addressed, the problem will return!! Here is an example of a transactional process, showing the three types of corrective action If there is a documentation error, the immediate action is the re-inspection of the paperwork for that specific error. This might also include reworking the document to get it back to an acceptable condition The permanent action is the changing of the form so that it cannot proceed without the correct information going to the document. The preventive action is the mistake proofing of all similar processes so that the error cannot be made again in the future 18  Examples of Corrective Actions Part removed and Product Design process replaced in redesigned to changed to product, account for part require variation retested variability analysis testing on similar supplier parts Immediate Permanent Preventive If preventive not addressed, the problem will return!! Here is another example… 19  Problem Solving Process 1. Identify Problem 2. Identify 8. Validate Team Problem 7. Follow Up 3. Immediate Plan Solving Action Process 6. Complete 4. Root Cause Plan 5. Action Plan A common, simple and highly recommended 8 step problem solving process. 20  Step #1 – Identify the Problem Identify the Problem Clearly state the problem the team is to solve. Very important! Teams should refer to problem statement to avoid getting off track. Use 5W2H approach Who? What? Why? When? Where? How? How Many? EXPLAIN: The first, and one of the most important steps, is to identify the problem to address. Meetings can be drawn out and lose focus when the problem is unclear.. Key elements of a clearly identified problem include: the gap (pain) that exists, when and where the problem occurred (timeframe), quantifying the gap (impact), and importance to the organization to better understand the urgency Insert 30 sec clip of Apollo 13 “work the problem” https://youtu.be/u-IHTW6Ggyo?si=sRTj1iFB2hASL4kS 21  WHO? Step #1 – Identify the Problem Is impacted? Is involved? WHAT? Do we need to solve? WHO? Must/should be done? Trends have we seen? WHEN? HOW Was the problem first observed? WHAT? MANY? WHERE? Is the problem observed? (Location, area, facilities, etc.) 5W2H WHY/WHICH? HOW? WHEN? Is it a problem? Any previously known explanations? HOW? Is the problem observed? (Symptoms) WHY? WHERE? HOW MANY? Frequency Quantity SAY: One of the challenges of clearly defining the problem is that distractions can come from: focusing too much on the symptoms, or too fast on the solutions, or playing the blame game. In a good RCA, asking the right questions in the right order and letting the answers lead you to a great problem statement can prevent distractors from creeping in. SAY: The 5 W’s and 2 H’s approach can help you get there. Simply answer the who, what, where, when, why, how, and how many to help better define the problem. EXPLAIN: When answering this question, What? try to clearly describe the issue and determine the desired result when resolved or achieved. Why? try to define why the problem is occurring and why solving the problem is necessary. Where? Try to clarify where a problem occurred or where a solution is 22 likely to arise. When? Try to identify the timeline for when a team can implement a resolution to its problem or perform each step toward achieving its goal. This step may include creating delivery dates for each step of a project. Creating milestones and deadlines during this phase can identify the necessary order of actions and help determine any contingencies within the project's steps. Who? (This might refer to several different aspects of a problem) - Who's overseeing the entire process? Who's it affecting? How? How much? May also refer to the quantity of a product, frequency of occurrence, etc? 22  Step #1 – Identify the Problem (Main Activities) Gather and 1 Analyze Relevant 3 Define Scope/Boundaries Data 2 Involve Affected People in Problem 4 Focus on the Facts Definition 3/11/2024 SAY: On the road to solving the problem, there are some key activities that should occur when attempted to define the problem. These include: (1) gathering/analyzing data, define boundaries (to avoid scope creep), (3) involve affected people (customers, injured worker, etc), and focus on the facts. 23  ACTIVITY: Problem…What’s the Problem? Time: 15 minutes 3/11/2024 Problem…What’s the Problem? Object of Play Employ the 5w2H method of asking seven simple questions and write a problem statement from one of the provided scenarios. The object is to adequately describe the problem in order to be able to solve it. Number of Players Divide participants into small groups of 3-4. Time to Play 15 minutes How to Play 1. Provide each group with 1 of the 2 scenarios. 2. Allow time for the groups to their scenarios and draft a clear problem 24  statement. 3. When the class regroups, have a representative from each group read aloud their scenario and state the problem as they identified it. 4. Alternative Option: Select 1 person in each group to play the role of distractor: (drawing attention from the task at hand, attempting to bring in other unrelated issues, etc). 5. Ask the class to agree or disagree. Scenario #1 Manufacturer At a plastic pipe/fitting manufacturer, off-spec parts are ending up in the backflush. If identified (visual inspection), the affected parts must be sent back for rework, thereby increasing the overall cost of manufacturing, creating higher inventory levels and increasing risk since some of the defects may not be detected until later in the process, or worse, they may end up being incorrectly shipped to the customers. This problem is observed in the quality department and even downstream departments (i.e., wrapping, pipe yard, or distribution). In some cases, the problem has also been seen in the field resulting in customer complaints and costly field repairs and replacements. This problem affects the quality technicians tasked with trying to inspect for the error and the line operators who are being asked to react accordingly and rework affected parts while still maintaining products in production. Not to mention, the company as a whole is affected in terms of cost and reputation. This has been an ongoing issue going back as far as memory serves with the long-term employees, but with increased volume, new formulations, and aging equipment, the impact and severity of this problem has increased rapidly over the last year. Customer (in-field installation and service) complaints, increased warranty costs, manufacturing non- conformance reports (NCR), complaints from the quality and production have all been noted. There is an observed 50,000 parts per million (PPM) for this specific defect, taking into consideration rework completed in- house and observed defects in the field. This specific issue seems to be limited to a particular region where the turnover rate has also skyrocketed 24 over the past 18 months. Your Turn! Can you think of a problem you have encountered in your personal or professional life, or a problem you are currently tasked to solve. Employ the preceding method of asking seven simple questions and see where it takes you. Question 1: What is the problem that needs to be solved? Question 2: Why is it a problem? (highlight the pain) Question 3: Where is the problem observed? (location, products) Question 4: Who is impacted? (customers, businesses, departments) Question 5: When was the problem first observed? Question 6: How is the problem observed? (symptoms) Question 7: How often is the problem observed? (error rate, magnitude, trend) Strategy This game is about asking the right questions and filtering thorough distractions to define a problem. It’s about engaging all the participants so the team can get the greatest leverage for solving the problem. Takeaway Many problems require more or less interrogation. If the players avoid the issues or prefer to not admit a hard truth, you could have people addressing the wrong problems. So, as the meeting leader, be aware of the dynamics between the players and foster open conversation around the difficult questions. 24  Step #2 – Who is on the Team? Identify the Team A problem cannot be solved thoroughly by an individual, use a team! Should consist of SME or this with a high degree of knowledge experts Small group of people (4-10) with process and product knowledge, available time and authority to correct the problem Must be empowered to “change the rules” Encourages ownership & buy-in of the solution Should have a designated Champion Membership in team is always changing! SAY: A problem cannot be solved thoroughly by an individual, so use a team! ASK: Who should be on the team? EXPLAIN: In most cases, a team of affected individuals should be brought together to discuss the issue. More problems can arise when the right people are not involved but try to keep the team between 4-10 people. More people than that can slow down the process. There should be a “Champion” to oversee the problem until it is resolved. They may play an active role in the discussions, or simply make certain the teams are meeting and that progress is being made. May also be responsible for taking issues up to leadership. As the problems become more defined and analysis starts to drive the 25 team in one direction, it is normal for the team members to change. Initially, step 1 will have the most team members, and towards the end of this process, maybe only a few people are still actively working the issue. During the root cause analysis step, new members may be asked to participate based on their expertise in a certain area. 25  Step #2 – Team Roles & Responsibilities Team Roles and Responsibilities Champion: Mentor, guide and direct teams, advocate to upper management Leader: day-to-day authority, calls meetings, facilitation of team, reports to Champion Recordkeeper: Writes and publishes minutes Participants: Respect all ideas, keep an open mind, know their role within team SAY: Of all the people who might participate on the team, there should be 3people with designated roles: The following is a list of roles and responsibilities 26  Key Ideas for Team Success Define roles and responsibilities Identify external customer needs Step #2 – Identify internal customer needs Include appropriate levels of organization Team Solicit input from everyone Clearly define objectives and outputs Success Possess respect, care, cooperation, trust among the members Good meeting location: - Near work area for easy access to info - Quiet for concentration and avoiding distractions SAY: There are a few things to key in mind to ensure the success of the team. EXPLAIN: 1) Each member must know what they are expected to “bring to the table”. This assures the team that all needed areas are adequately covered before beginning. 2) Secondly, the team must identify external customer needs - what outputs and results are expected from the customer, and how will they be communicated (at the end of the project, during, only when needed?) 3) Next, the must should consider internal needs. What processes and procedures need to be followed, and what systems are available or required. This may include a corrective action process. 4) Ensure appropriate levels of management is supporting the team’s effort; without it, the team will have a hard time implementing any 27  actions or activities that will result from the effort. 5) Clearly defined objectives and outputs are essential, otherwise the team may try to attack issues outside the scope of the analysis or get sidetracked by other problems that each group may want resolved. 6) If all members are not involved in the discussions, there will be less buy-in to the resolution. Identify members who are not participating and ask for their opinions. Try to prevent certain individuals from dominating the discussion. 7) Good meeting location may not make the team perform any better, but will prevent other distractions and issues that can really impact the teams success 27  Immediate Action Activity implemented to screen, detect and/or contain the problem Step #3 – Must isolate effects of problem Immediate Usually “Band-aid” fixes Corrective Only temporary until corrective action is implemented (very costly, but necessary) Action Must also verify that immediate action is effective Make sure another problem does not arise from the temporary solutions Do not let temporary fixes become permanent solutions. SAY: The third step is to address the immediate action needed to keep the problem from spreading any further. EXPLAIN: Even though in the early stages you have likely not uncovered the root cause, we often still implement containment measures, some sort of band-aid, such as: sorting of parts or paperwork, re-inspection, rework, or recall to “stop the bleeding.” A check should also be made to see that the containment/immediate action kept the problem from spreading any further. Whatever immediate action is done, it should only be temporary, and not stay in place after the root cause has been identified. 28  The Difference between Permanent vs. Preventive Corrective Actions Preventive Permanent Made training a requirement to new employees Trained employee on proper machine use working in that area Changed product design to make parts easier Changed design guidelines to not allow for use of to assemble manually part in full scale production All documents that are critical to project are Specific customer document critical to project is identified with red folders identified with red folder Check for those software bugs added to checklist Update all customers with latest software revision and performed prior to release of software to fix problem Process developed to identify “at risk” patients for falls who require assistant Fallen patient given full-time assistant to provide help moving around hospital Ethics training developed and provided to all employees Employee fired for ethical violation EXPLAIN: We mentioned earlier that most organizations stop with the permanent corrective action. Let’s review a few examples of CAs to make a good distinction. ASK: What examples of corrective actions come to your mind for common problems you see in your workplace? DO: Make a list of participants responses on a flipchart. DO: Split participants into small groups to classify the complied list as immediate, permanent, and preventive. SAY: While immediate and permanent corrective actions are important in resolving issues for existing problems, preventative actions are an even more effective strategy 29 to proactively address recurrence. 29  ACTIVITY: Taking Action! Time: 15 minutes 3/11/2024 Taking Action! Object of Play The object is to adequately classify the various types of actions. Number of Players Divide participants into small groups of 3-4. Time to Play 15 minutes How to Play 1. Read off 2-3 of the provided scenarios and their accompanied corrective actions. 2. Ask the class to classify the corrective actions as immediate, preventive, or permanent. 30 Corrective Action Example 1: Preventing Workplace Accidents Scenario A manufacturing organization has seen an upsurge in workplace accidents as a result of insufficient safety protocols. Electric shocks, wounds, burns, and slips and falls are a few of the accidents. Injuries, absenteeism, litigation, and penalties have all been caused by these mishaps. Corrective Actions  Conduct safety training programs for all workers to inform them about potential risks and hazards in the workplace and how to deal with or avoid them.  Perform routine hazard assessments and audits to find and get rid of any harmful working circumstances or methods.  Improve the tools and equipment for employee safety, such as protective gear, gloves, goggles, helmets, fire extinguishers, etc.  Create a safety committee and a reporting mechanism to facilitate employee input on safety-related issues and worries.  Review and revise the safety policies and practices to make sure they are complete, understandable, and compliant with the necessary laws. Corrective Action Example 2: Addressing Product Defects Scenario One of a food processing company’s well-known products, a ready-to-eat salad, has reoccurring quality flaws. The flaws include rotten dressing, wilted lettuce, strange objects, and inaccurate labeling. Customer complaints, returns, refunds, and reputational harm have all resulted from these flaws. 30 Corrective Actions  Putting in place quality control measures including internal audits, tests, sampling, and inspections to find and fix any flaws before they reach the customers.  Incorporating consumer feedback into the process of product development and improvement to better understand and satisfy customers’ wants and expectations.  Transparently informing the clients of the quality problems and the steps being taken to fix them. This can entail sending out necessary alerts, recalls, or apologies.  Retaining the patrons’ loyalty and happiness through providing rewards or payments. Corrective Action Example 3: Managing Disruptions Scenario When a significant supplier is severely disrupted by a natural disaster, a retail chain faces a supply chain crisis. Some of the chain’s best-selling products face inventory shortages and delivery delays as a result of the disruption. This has an impact on the company’s sales, earnings, and customer service. Corrective Actions  Diversifying the supplier network to reduce reliance on a single source while increasing flexibility and resilience in the event of disruptions.  Using cloud-based platforms, artificial intelligence, or blockchain technology to improve visibility, coordination, and collaboration across supply chain participants.  Improving inventory management by optimizing stock levels, replenishment cycles, and distribution channels utilizing data 30  analytics, forecasting models, or inventory optimization tools.  Proactively communicating with clients about the supply chain situation and estimated delivery timelines. This could include offering several options or solutions to satisfy their requirements or preferences.  Negotiating better terms or conditions with suppliers to reduce the risks or losses associated with the disruption. Corrective Action Example 4: Navigating ESG Concerns Scenario A production company is under fire from the public for its environmental practices and a lack of social responsibility efforts. The corporation has been accused of contributing to greenhouse gas emissions, the development of electronic waste, human rights breaches, and the digital divide. These allegations have harmed the company’s image and reputation among its stakeholders. Corrective Actions  Adopting green activities such as lowering energy use, using renewable energy sources, recycling products, and reducing waste output.  Implementing social responsibility programs like community assistance, diversity and inclusion promotion, fair labor practices, and human rights protection.  Developing governance rules and procedures to ensure accountability, openness, integrity, and adherence to applicable laws and regulations.  Engaging with stakeholders such as customers, employees, investors, regulators, and the media to communicate the company’s ESG values, goals, and actions and solicit feedback and suggestions. Corrective Action Example 5: Preventing Employee Injuries 30 Scenario Employee injuries and pain are on the rise in warehousing facilities due to poor workplace ergonomics. Back discomfort and neck strain. These injuries harm the employee’s health, well-being, and productivity. Corrective Actions  Begin ergonomic assessments for the warehouse environment. These evaluations should thoroughly check the suitability and comfort of employees’ workstations, shelves, and equipment.  Invest in ergonomic solutions tailored to warehouse personnel. Adjustable workstations, conveyor belts, lifting aids, and safety equipment may be included to give ideal support for employees’ posture and movements while performing jobs like as lifting, packing, and stocking.  Educate staff on how to fit their workstations with warehouse tasks, maintain optimal posture while lifting and stacking, and develop healthy habits appropriate to their roles.  Introduce safety equipment that addresses ergonomic concerns in the warehouse, such as back braces, anti-fatigue mats, and ergonomic hand tools. Strategy Takeaway 30  Problem Solving Tools brainstorming flowcharting cause & effect diagrams (fishbone) Step #4 – pareto charts barrier analysis Finding the change analysis Root Cause 5 Why failure mode, effect & criticality analysis fault tree analysis EXPLAIN: Once evidence is collected, it is necessary to find the truth among the noise. There are tools that can help you get to the root cause of a problem. While there is no “right” or “wrong” option, some tools are more ideal/effective than others in depending on the situations. And in some case, it may be beneficial to combine a couple of the methodologies/technique for greater results. For example, after brainstorming, you may use the pareto principle to determine which “causes” to focus on. And after selecting the most probable cause, you may use cause-and-effect and the 5 Why’s methodology until you get to the root cause. SAY: At IPEX, we recommend the use of the Cause-and-Effect diagram or the 5 Whys. Leveraging any combination of these techniques strategically enhances our problem-solving capabilities, helping up to make informed decisions and drive continuous improvement. 31  Introduction to 5 Why’s Introduction to 5 Why’s Ask “Why?" as many times as necessary Stop when the corrective actions do not change Stop when the answers become less important Stop when the root cause condition is isolated SAY: One of the best techniques when performing a root cause analysis is called the “Five Whys.” This approach is simply asking “why?” over and over again, rather than accepting the first answer to bring you closer to what’s actually causing the problem. EXPLAIN: Note that, while called the “Five Whys,” it can be only a few whys or dozens before you reach the root cause of your problem. Use the 5 Why’s methodology until you get to the root cause. The root cause will be a process that initially caused the problem to occur. People, departments, groups or machines are not the root cause. The best way to understand this technique is through an example. SAY: This question-and-answer exercise leads to the root cause of the machine stopping problem. 32 ASK: In this simple example, do you think we have identified the root cause? What is it? 32  Digging for the Root Cause Car won’t start PROBLEM Dead Battery How do we find Root Cause? Did not turn off lights EXAMPLE: Let’s build upon an earlier example. ASK: Do you think we found the actual root cause? SAY: Try to take the root cause one more step to make sure the team addresses the same problems at the company wide level, or outside of their own department or group. 33 5 Whys? Problem/Symptom: Car Won’t Start Battery is Dead. I left the lights on last night. I forgot to turn them off. I did not know that they were on when I left the car. No visual / audible sign that the lights are on. More practice. 34 5 Whys? Problem/Symptom: Associate was injured performing their job Associate was placing a heavy box on the top shelf of their station. The box’s intended space for storage is filled with another raw material. There is not enough space in the area. Some obsolete material is taking up precious space. This station was never 5S’d to get rid of old products. DO: Review this example. EXPLAIN: There are benefits to doing a 5Why analysis: Quickly identifies the root cause of a problem Illustrates how one process can cause a chain of problems Helps determine the relationship between different root causes No need for complicated evaluation techniques SAY: When to use the 5 Whys: For simple to moderately complex problems When human error may have contributed to your problems 35  ACTIVITY: The 5 Whys Game Time: 10 minutes Part 1 3/11/2024 The 5 Whys Game Object of Play The 5 Whys game mirrors that motive to move beyond the surface of a problem and discover the root cause, because problems are tackled more sustainably when they’re addressed at the source. Number of Players 5–10 How to Play (10 minutes) 1. Display/Write the problem in an area visible to all the group members. 2. Below the problem statement, write the word “Why?” five times in a column and draw lines to create columns for each player’s set of notes. 3. Distribute sticky notes to each player and ask them to number five of 36  them 1 through 5. 4. Ask the players to review the problem statement and ask themselves WHY it’s a problem. Then ask them to write their first response on sticky note 1. 5. Tell the players to ask themselves WHY the answer on sticky note 1 is true and write their next response on sticky note 2. 6. Again, tell the players to ask themselves WHY the answer on sticky note 2 is true and write the response on sticky note 3. 7. Repeat this process in numerical order until every numbered sticky note has a response written on it. 8. Ask the players to approach the wall and post their responses, starting with 1 at the top and ending with 5 on the bottom. 9. Review the “Why” columns with the group and note commonalities and differences. 10.Allow for discussion. (10 minutes) The 5 Whys game is based on a game by Sakichi Toyoda. 36  ACTIVITY: The 5 Whys Game Time: 15 minutes Part 2 3/11/2024 The 5 Whys Game Object of Play The 5 Whys game mirrors that motive to move beyond the surface of a problem and discover the root cause, because problems are tackled more sustainably when they’re addressed at the source. Number of Players 5–10 How to Play (15 minutes) Now, 1. Rewrite the problem statement on a sheet of flip-chart paper. 2. For classes larger than 5 participants, divide the class into 2 groups. 3. Give a volunteer for each group five clean sticky notes to write on, and 37  advise them to work as a group to build consensus on which of the five “Whys” in the columns offer the most meaningful insight into the problem. 4. Ask the volunteer to rewrite the “Whys”—one per sticky note—as the group agrees on them. 5. Once they’re all written, tape the five sticky notes into a final column under the problem statement. 6. If you have time, move into a discussion around “what’s next.” Strategy This game is about understanding the root cause of a problem using the 5 Why method so that people can get the greatest leverage out of solving it. When leading this game, encourage the players to be honest. This is the single most important strategy. If the players avoid the issues, the game doesn’t yield good information. And in a worst case scenario, you could have people actually addressing the wrong problems. So, as the meeting leader, be aware of the dynamics between the players and foster open conversation around the difficult question of “why”. Another important practice is to ask the players to write the first thing that comes to mind each time they ask “Why?” If they jump immediately to the perceived root of the problem, they may miss the opportunity to see the stages, which are valuable to know for problem solving at different levels. Finally, many problems require more or less interrogation to get to the root. Ask “Why?” until you feel the group is really getting somewhere. Five Whys is a healthy place to start, but don’t interpret it as a fixed number. Build longer WHY columns if necessary, and keep going until you get the players to meaningful insights. The 5 Whys game is based on a game by Sakichi Toyoda. 37  Cause-Effect (also called “Ishikawa” or “Fishbone”) Diagram is a data analysis/process management tool used to: Organize and sort ideas about causes contributing to a particular problem or issue What is a Gather and group ideas Cause-Effect Diagram? Encourage creativity Breakdown communication barriers Encourage “ownership” of ideas Overcome infighting SAY: Another commonly used method is the fishbone diagram (also called the Ishikawa and herringbone diagrams). EXPLAIN: A Cause-Effect Diagram (or fishbone) is typically generated in a group meeting and produces a visual aid to categorize potential causes and explore their interrelationships by tracking back to the potential root causes of a problem by sorting and relating them in a structured way 38  Cause-Effect Diagram Steps used to create a Cause-Effect Diagram: 1. Define the issue or problem clearly 2. Label potential issues. 3. Brainstorm all the possible causes of the problem. As each idea is given, write it as a branch from the appropriate category. 4. Write sub-causes branching off the primary causes. CAUSES EFFECT Machines Method Manpower (Equipment) PROBLEM Environment Materials SAY: This method is referred to as Fishbone because it looks like a fish skeleton. A typical fishbone diagram includes six ribs, each labeled with a potential issue to address. EXPLAIN: To work through an RCA using the Fishbone, follow these steps. CLICK to display each step. 1. Define the issue or problem clearly and write it at the head of the fish. 2. Write the categories of causes as branches from the main arrow. 3. Brainstorm all the possible causes of the problem. As each idea is given, write it as a branch from the appropriate category. NOTE: Causes can be written in several places if they relate to several categories. 4. Write sub-causes branching off the causes to generate deeper levels of causes. NOTE: Layers of branches indicate causal relationships. 5. When the group runs out of ideas, focus attention to places on the chart where ideas are few. 39 Causes are not limited to the listed categories but serve as a starting point and some organization use a different set of labels/categories. 39  Cause-Effect Diagram Example EXPLAIN: In this example, a Fishbone diagram is applied by a manufacturing team to try to understand the source of periodic iron contamination in their product. The team used the six generic headings to prompt ideas. Layers of branches show thorough thinking about the causes of the problem. SAY: Note that some ideas appear in two different places. "Calibration" shows up under "Methods" as a factor in the analytical procedure, and also under "Measurement" as a cause of lab error. "Iron tools" can be considered a "Methods" problem when taking samples or a "Manpower" problem with maintenance personnel. 40  Next Steps – Cause & Effects Diagram After completing the Cause-Effect Diagram, take the following actions: 1. Rank the ideas from the most likely to the least likely cause of the problem or issue 2. Develop action plans to address the root causes and prevent reoccurrence. Expected Outcome  Individuals have become part of a problem-solving team  The sources of problems/other issues have been identified using a systematic process  Team members see issues from a similar perspective  Ideas and solutions are documented  Communication is improved  Team members assume ownership SAY: The cause-effect diagram can be enhanced by following up with an action plan and responsible owner for each action. EXPLAIN: 41  ACTIVITY: GONE FISHIN’ Time: 15 minutes 3/11/2024 Gone Fishin’ Object of Play Promote a general view of a problem for participants to identify possible causes for an effect or problem using the fishbone diagram. Useful to explore root causes of a complex problem, generate insights, and facilitate discussions to address issues Number of Players Group size 4-10 Time to Play 15-20 minutes Instructions 1. Use prepared problem statement or find a site-specific issue prior to 42  the meeting to discuss during this activity. 2. Draw a fishbone diagram on a large surface (whiteboard/flipchart) and place a sticky note with the problem statement in the “head.” 3. Discuss relevant categories of causes of the problem with the group and place a sticky note with each category at the end of each “bone.” Categories could be: Methods, Machines (equipment), People (manpower), Materials, Measurement, Environment, 4. Do Silent Storming (10 minutes) on “Why the problem may be happening?” 5. Each participant plays back their findings on the map, placing each of their sticky notes on the branch of the appropriate category. Strategy Takeaway 42  Corrective Action Plan Review prior RCAs to determine what corrective actions were implemented for similar events. Step #5 – Permanent Corrective Action Review and evaluate actions taken to address those previous events. Do not limit actions in the plan; include some permanent or preventative or actions to eliminate the vulnerability. Provide feedback /Ask got suggestions. Identify what was learned and who needs to be informed. Present any additional recommendations of the RCA team which were not included in the action plan. Must verify the solution will eliminate the problem. Verification before implementation whenever possible. Verification vs. Validation SAY: Corrective action is sometimes perceived as the activities to replace, repair, rework or put right nonconforming products (the quick fix). These activities form part of the containment actions we discussed in Step 3. If we stopped there, we’d fall short of addressing the ultimate cause and only (D3) correct symptoms. Verification involves testing of the proposed solution to make sure it will do what the team thinks it will prior to a full scale implementation. Often times, the solution can create additional problems. If the solution will not work, it is better to find out in a beta test environment, rather than under normal operating conditions. Validation means that the corrective action not only worked, but it was effective long term (withstanding all possible process issues) 43  Writing an action plan Step #5 – Permanent Corrective Action Define exactly… What actions will be taken to eliminate the problem? Who is responsible? When will it be completed? Get stakeholder feedback Define how the effectiveness of the corrective action will be measured. SAY: RCA doesn’t come with instant results, but getting to the root cause of a problem solves it for good. After coming up with an effective solution, you’ll need to put a plan into action. The plan should define: EXPLAIN: The goal of problem-solving is to overcome obstacles and find a solution that best resolves an issue. The implementation of a solution requires planning and execution, where the focus should be on short implementation cycles with testing and feedback and not trying to get it “perfect” the first time. 44  ACTIVITY: Good Ideas! Time: 20 minutes 3/11/2024 Good Ideas Object of Play To come up with ideas for inter-team and inter-departmental collaboration for achieving common goals to correct organization problems. Number of Players Time to Play 20m Materials flipchart felt-tipped pens timer whistle 45 Instructions Specify a common goal – resolution of a specific problem – that requires collaboration among different functions. Ask the class to brainstorms a list of ideas in response to the question, “How can I (or my function) help to achieve this goal?” Encourage the group to produce a long list and shrink it down to the top five ideas. Announce a suitable time limit. One minutes before the end of the allotted time, blow a whistle to get participants' attention. Ask each group to identify its top three ideas for achieving the common goal. Ask individual participants to take notes about the final list. Explain that every participant would need this information during the next phase of the activity. Ask members of the group to brainstorm a list of ideas in response to the question, “How can employees from different departments work with each other to achieve our common goal?” Encourage participants to use their ideas from the previous round in a flexible fashion. As before, encourage each group to begin with a long list and whittle it down to the top three ideas. Give an index card or a piece of paper to each participant. Ask participants to write down five ideas in response to the question, “How can I individually contribute to the achievement of the common goal?” Tell participants that they could record earlier ideas from their groups, or ideas from other groups, or new ideas. Announce a suitable time limit. Strategy Takeaway 45  Steps #6-8 Complete Action Plan Follow Up Plan Validate and Celebrate Step 6 Step 7 Step 8 What actions will be completed in the future to Make certain all actions that are defined are ensure that the root cause has been eliminated What were the results of the follow up? completed as planned by this corrective action? If problem did reoccur, go back to Step #4 and If one task is still open, verification and validation Who will look at what data? re-evaluate root cause, then re-evaluate is pushed back corrective action in Step #5 If the plan is compromised, most likely the If problem did not reoccur, celebrate team How long after the action plan will this be done? solution will not be as effective success! Document savings to publicize team effort, What criteria in the data results will determine obtain customer satisfaction and continued that the problem has not recurred? management support of teams EXPLAIN: Step 6 is simply making sure to complete the action plans defined in Step 5. You cannot verify or validate until all actions have been completed. If the actions are not fully completed, or only partially completed, the effectiveness of the solution will be jeopardized. EXPLAIN: Step 7 involves involves preparing the team for action, once the data analysis of the solution is complete. Who should be collecting the data, and for how long? What type of data results will be deemed acceptable? EXPLAIN: Finally, the team should review the data results to conclude whether the root cause was adequately defined, or that the corrective action put in place was effective. If the problem still exists. Go back to either Step #4 and redefine the root cause, or Step #5, to readdress the corrective actions put in place. If the problem went away, formally close the problem and celebrate success. It is extremely beneficial if a financial 46 savings impact of resolving the problem is calculated. Many companies will redistribute a percentage of the cost savings back to the team members to further support the importance of solving problems 46  Common Mistakes to Avoid Mistake #1: Jumping to conclusions Jumping to conclusions without thoroughly examining the available information often leads to implementing quick fixes that do not address the root cause of the problem. Mistake #2: Focusing only on individual errors Solely blaming individuals for incidents without considering the broader organizational context can lead to a culture of blame and an unwillingness to report incidents in the future. Mistake #3: Neglecting to involve the right people Involving all pertinent stakeholders, including employees directly involved in the incident, supervisors, and management in the RCA process aids in collecting a variety of viewpoints and promotes a sense of collective accountability. Mistake #4: Inadequate documentation Documenting every step of the RCA process, including the incident description, investigation, root cause identification, and proposed corrective actions helps to ensure that all stakeholders are aware of their responsibilities and can track the progress of the implemented solutions. Mistake #5: Failing to follow up on corrective actions Regularly reviewing the implemented solutions and make any necessary adjustments to ensure that the root cause is fully addressed, and the risk of recurrence is minimized. SAY: Root Cause Analysis (RCA) can be highly effective in addressing workplace issues when done correctly. However, there are some common mistakes that organizations make when conducting RCA. 47  What does a good RCA look like? …Focuses of the investigation should …inter-disciplinary, be “WHY the event involving experts occurred” not “WHO from the frontline services …internally consistent …includes participation by …reviews and the leadership of the …continually digs organization & those most evaluates the deeper by asking effectiveness of closely involved in the why, why, why at processes & systems RCA initiatives on a each level of cause regular basis, and effect adjusting as needed. SAY: A Complete & Credible Root Cause Analysis is… ASK: Can IPEX afford NOT to do RCA? 48  One problem may have more than one root cause ∟One root cause may be contributing to many Recap of problems RCA ∟When the root cause is not addressed, expect the problem to reoccur Prevention is the key! EXPLAIN: Here are a couple things to keep in mind when performing root cause analysis. Remember, just as one problem may have multiple root cause possibilities, one root cause may be causing multiple problems. When you do root cause analysis on a problem, you will have one root cause. However, if you look at all the “possible” ways in which it could go wrong, you will find multiple things that need to be improved. When you don’t get to root cause, the process that creates it continues to send more problems and the problem will eventually return. Many times, a short period of time without reoccurrence does not mean the root cause has gone away. SAY: The effectiveness of any Root Cause Analysis (RCA) relies on the accuracy and quality of the input data. That’s why it is necessary to have a reliable incident reporting 49 system, set parameters, and specified tools in place to be used when the situations warrants it. 49  What to do when things go wrong? 3/11/2024 ASK: What do you do when things go wrong? PROMPTS: equipment failures, unexpected downtime, employee injury, slow start up, unable to get product in-spec… DISCUSSION: Is there a process in place for reporting/capturing these various types of problems? Are people comfortable with the process – do the follow it? Does it encourage people to be open/honest or is it founded on a “blaming” foundation. 50  IPEX SYSTEMS & TOOLS – Production & Maintenance 3/11/2024 SAY: These tools have been established to standardize the why we perform root cause analysis at IPEX as it relates to production, maintenance, or other operational problems that may arise. EXPLAIN: How participants can access the tools. 51  IPEX SYSTEMS & TOOLS – Quality 3/11/2024 SAY: EXPLAIN: 52  IPEX SYSTEMS & TOOLS – Quality 3/11/2024 SAY: EXPLAIN: 53  IPEX SYSTEMS & TOOLS - HSE 3/11/2024 SAY: If a Health, Safety, or Environment event occurs on your site, the new Cority system is the tool to report and investigate the issue. EXPLAIN: Within Cority, you can use either the 5Why tool built into the system or the root cause feature which allows you to link actions to findings and assign/track them to completion all in a single system. There is also an option to use the IPEX standard documents to help facilitate your RCA and upload it into a reported event within the system. Additional, in- 54 depth training on how to use Cority to investigate root causes of HSE incidents is available. 54  Review You learned: How to identify the Why it is important The process for How basic quality root cause proper root cause tools can be applied analysis to examples REVIEW: This is what the students should have learned in this course:  How to identify the root cause,  why it is so important for company success,  the proper process for root cause analysis,  and how you can apply basic quality tools to the problem-solving process. 55  Now, let’s apply the skills… 3/11/2024 EXPLAIN: We’re now going to move into the final activity of the session and look at a few case studies from IPEX locations. The class will be divided into small groups with each group being assigned a case study. In your group, review the case study, following the 8-step process for problem-solving, 1) Identify the problem – Write a clearly defined problem statement. 2) Identify the team – Determine the position within a facility who should be on the RCA team; select a leader, champion, and recordkeeper; identify any additional participants 3) Corrective Action – Describe initial containment actions 4) Root Cause – Determine which tool is appropriate to help resolve your problem; use 5Why or Fishbone to do the RCA 5) Action Plan – Use your finding in step 4 to create an action plan to correct/prevent the issue from reoccurring, assign responsible and target dates 56 6) Complete Plan/Action 7) Follow Up on Action – Note what type of data, information or results are necessary to confirm action(s) completed 8) Validate – Ask What was intended? What actually happened? What did we learn? Who are we going to tell? DO: Allow the groups ~30-45 minutes to work the steps above and prepare to present their case studies in 10-15 increments once the group reconvenes. 56 Root Cause Analysis Practical Training In this training, we will focus on primarily finding root cause of the problem! Learn by doing! Practical training guidelines: 1. Split into groups – minimum of 3 persons per group 2. Go for cross-functional thought 3. 20 mins to collaborate and make decisions on: - Should we use fishbone diagram? - Should we use a 5-Why? Both? 4. 20 mins to reconvene and discuss 5. Produce final root cause analysis 57 Root Cause Analysis Case Studies 58 Example #1 An entry-level extruder operator was assisting on a line start–up of 12”, sch80, CPVC pipe. The operator was originally assigned to a different line but because of a shortage in manpower (the shift was down 3 operators), quality issues with the pipe being produced, and equipment breakdowns with the in-line saw, he was reassigned to manually cut the pipe on this line while maintenance troubleshooted the in-line saw. As he was manually cutting the pipe and removing the scrap from the transfer table, the stack of scrap pipe in the cart collapsed, rolled over and pinned the operator between the table and pipe cart. The operator suffered a contusion and sprain of the knee injury. At the time of the incident, there were 10 pieces of pipe on the cart. A single 20’ stick of 12”, sch80, CPVC pipe weighs approximately --- and the full pack of 8 sticks of pipe weighs approximately --- This was the operator’s first time working the larger diameter extrusion lines. Site procedures indicate that scrap carts should be packaged at or below the required pack limit. 59 Example #2 Employee was using the stand up grinder to surface a newly fabricated fitting when their hand slipped due to glycol residue on the fitting. When their hand slipped it contacted the abrasive wheel on the grinder and created an abbrasion to their right middle finger; minor injury. 60 Example #3 The maintenance employee was using a sledgehammer to straighten a part of a cart, the employee hit the part from below instead of hitting it from top to bottom, the sledgehammer went straight through and hit the employee in the teeth. One of his teeth was chipped. 61 Example #4 I was troubleshooting the south side lifter on line 2 and as a precaution had cleared the beller of all pipes, put them to go straight out the end. While I was working on getting the lifter back in place, did not notice a pipe had come through the indexer. Said pipe dropped onto the lifter and fell onto the floor as the lifter wasn't in place. The pipe fell near my feet and missed hitting me. I went out of the beller and double checked that the beller functions were turned off. The small door that cuts off functions to the beller had closed and the sensor was re-engaged, this allowed the pipe in the trough to come through the indexer. I opened the door again and taped it to the control box as a precaution while I finished putting the lifter in place. 62 Example #5 On line 16 when there is 10' pipe and the pallet is almost full the pipe will hit the other pipe and spin causing the pipe to slide and spin. This causes the pipe to slide over to line 15 and hit the light motion sensor. Need to raise the light motion sensor about 18" if possible to prevent this. Blue card, after discussing with Extrusion and Maintenance I was ask to assign this to HSE to see if we are allowed to move the light motion sensor to 18" 63 Additional Examples Transfer Line blew off which resulted in material being blown on the ground. This is the 5th time this has occurred at this facility in the past 8mos. Uncontrolled release of non-hazardous materials (Conduit Powder Material), volume less than 0.5L. Waste hauler driver pulled out with all electrical and hydraulic components still hooked up to the compactor. This event pulled everything off the wall and caused approximately two gallons of hydraulic oil to be leaked in close proximity to a storm drain. The oil was immediately contained. 64