|
Review the processes
Identifying the processes that were in place before the failure occurred is extremely important in order to prevent the incident from happening again. Recurring problems are symptomatic of not managing by process.
A thorough investigation includes a review of the processes that produce the failure. (It’s much like a mechanic who must know how the transmission works in order to explain why the transmission failed.) During the investigation, a clear understanding of the current work process helps explain what specifically was being done to lead up to the failure. Secondly, the process needs to be well understood so that specific improvements can be made within the process to ensure that the failure doesn’t happen again.
Remember: The best solutions are all actions that will be implemented within the work processes.
|