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Root Cause Analysis Template 1
Root Cause Analysis Template
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3) The technician, Joe Smith, manually entered the temperature as well as other process
parameters. According to the computer log he manually entered 525 degrees F but did
not hit the <Enter> key and after 10 seconds the computer defaulted back to the 400
degree F temperature.
4) Technician Joe Smith performed all shut down and data preservation procedures correctly
and notified his supervisor within an appropriate amount of time.
5) All other cable products have process profiles built into the lines to prevent any manual
entry of process and temperature data. This safeguards against any operator error in
manually entering process parameters.
Based on the above findings the investigative team has determined that the root cause for the
TruWave trial cable failure was operator error in that the manual temperature setting for the
extrusion device was incorrect. While the operator attempted to set the temperature correctly, he
did not hit the <Enter> key after setting the temperature and did not ensure all settings were
correct before initiating the cable run.
CORRECTIVE ACTION
As the purpose of the RCA is to determine the root cause of a problem, it should result in some
corrective actions that may be taken to ensure the same problem is not repeated. Often, these
corrective actions will result in changes to a project’s scope, schedule, or cost. It is imperative
that all of the findings and corrective actions are detailed and formally communicated with the
project team so changes can go through the change management process and be implemented in
the project plan upon approval.
Based on the findings of the TruWave cable failure event on June 1
st
, 20xx the RCA team has
determined the following corrective action to prevent a repeat of this incident:
All project teams establish process parameters within which their trial cables must be built on the
cabling line. Previously, line technicians would manually enter process parameters into the line
computer since these cables were not yet part of production. The RCA team proposes that
process parameters for trial run cables also be pre-programmed into the line computers prior to
trial runs in order to prevent entering incorrect data as a result of human error. Under this new
process line technicians would simply select the correct pre-programmed file name associated
with the trial cable instead of manually entering 30 lines of process parameters. The expected
result of this corrective action is the elimination of human error associated with future trial
cables runs.
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