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The True Root Cause of Field Failures September 16, 2012

Posted by Tim Rodgers in Management & leadership, Organizational dynamics, Product design, Quality.
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Field failures are always unfortunate, sometimes costly, and they will always happen. Preventing field failures should certainly be the goal of all product development, manufacturing, and quality assurance organizations. However, given that failures will occur, I think the more significant issue is whether or not the organization can learn and make the necessary changes to eliminate the root cause.

Unfortunately many teams perform only a superficial investigation of root cause and address only the immediate, proximate cause of the failure. This might be a batch of defective parts, or an incomplete work instruction, or a badly-specified assembly drawing. The corrective action in these cases may be targeted to ensure that this particular field failure won’t happen again, but the question that should be asked is: “How do we know that a similar problem won’t happen?”

You have to dig deeper to understand if the failure was a low-probability, outlier event, or if there’s a systemic issue in the design, or production, or testing, or management, or other processes that will surely cause another, potentially more-serious problem. This is harder because it requires the organization to look in the mirror. Everyone knows about the Five Whys as a tool to determine root cause, but I don’t think the majority of organizations have the political will and courage to ask why those parts or work instructions or drawings were bad in the first place.

Was a there a missing process, or was the process not followed? Failure to understand responsibilities or dependencies or expectations? Conflicting business priorities? Lack of consistent management support? Shortcuts in the name of expediency or productivity or cost reduction? These are the kinds of root causes that will continue to result in field failures despite the most-dedicated “whack-a-mole” efforts.

Maybe that’s OK. Maybe the business’s leadership is willing to take a chance on quality instead of doing what’s necessary to create a culture that values quality. To be fair, every business has to decide what level of quality is good enough, and what they’re willing to do to achieve those goals. If that’s the case, then they shouldn’t be surprised when field failures occur. “The fault, dear Brutus, is not in our stars, but in ourselves.”

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