Here's how you can effectively conduct a post-mortem analysis following a manufacturing operation failure.

To analyze manufacturing operation failure effectively, Create a blameless environment, involve all stakeholders, gather data, reconstruct events, use the "5 Whys" technique, collaborate on solutions, document findings, share reports, and schedule prompt meetings with neutral facilitators. Identify root causes, implement corrective actions, monitor progress, and continuously improve processes to prevent future failures. Remember, the goal is not to assign blame but to learn from mistakes and strive for a more efficient and reliable manufacturing operation.

Post-mortem analysis following a failure in a manufacturing operation is a critical process aimed at identifying the causes and preventing recurrence. Start by carefully collecting data, including incident reports, equipment records, and employee statements. Then conduct an in-depth analysis using techniques like the Five Whys and Ishikawa diagrams to identify root causes. It is important to involve a cross-functional team of specialists to look at the problem from different angles. Develop and implement a corrective action plan supported by a time frame and responsible persons. Conclude the analysis by documenting lessons learned to improve processes and reduce risk in the future.

It’s not unusual to have less than perfect data. Collect the positive data as well as the potentially negative data to help eliminate things that don’t need to be changed. Be wary of proximate causes and symptoms. They can easily side track you into a false sense of understanding. Keep in mind that multiple system issues/failures often need to be addressed so hesitate to stop your investigation at the first root cause.

Use the basic tools like fish bone diagrams, Pareto charts, 5-whys, etc. to facilitate thinking beyond just the surface. Most problems warrant team efforts, even if you feel well versed in the subject. The tools aren’t just for you, they are useful to get teams to consider a wide variety of questions.

To assess impact, risk analysis must be considered by the stakeholders. As a team, the Failure Mode Effects Analysis (FMEA) rates Severity (S) (how a problem affects other operations, customer, safety, and other of aspect of failure) through the supply chain and end-user. Also, the FMEA ranks Occurrence (O) and Detection (D) to create a Risk Priority Number (RPN) by multiplying the SxOxD to better understand the impacts to the process and stakeholders. The higher the number, the higher the risk. When a problem is found after escaping the supplier to the customer, the team will contain suspect parts, conduct root cause, implement corrective action. When verified effective, the FMEA is updated. Severity can only be lowered by design change.

Understanding the impact and quantifying it is also important to justify any significant financial commitment to solving the problem. Basing your decision only on a Return on Investment will require a clear understanding of the financial impact or potential impact. A near miss doesn’t necessarily pencil out but if there could have been a serious safety, environmental, or business loss, it is the risk that may justify spending money. The impact, probability, and likelihood (think FMEA) combine to help you determine what to focus on.