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Topic Title: Root cause of a safety concern
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Created On: 10/26/2017 02:59 PM
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10/31/2017 12:19 PM
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Deepaknatraj Selvaraj


I'm working on a presenting problem (presence of a crush hazard on one of the machines we own). The machine was designed in 1950 - 1960s. I'm using A3 to solve the problem.

So while going through A3, I have the background as 'we noticed the crush hazard and OSHA regulation says, employer should eliminate recognized hazards'.

Current condition is we have a crush hazard and it is causing problems to run the machine. I have data in as to the dimensions of the machine and where the hazard exists

So my question is what is the root cause of the problem? Should i put root cause as poor design by manufacturer? If i say poor design, i cannot work on the design process of the manufacturer of the machine. So what should the root cause be?
10/31/2017 02:08 PM
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Mark Rosenthal

On the surface (with the limited information here), you have two things in play.

1) The machine is hazardous to operate. FIX IT and make the machine safe to operate. You know what to do. Don't wait.

2) When the machine was built and purchased in 1960, it likely met the requirements and standards of the time. Your "root cause" is less about what happened when the machine was designed, and more about why your organization allowed a hazard condition to persist as standards changed over the years.

Think of it this way -
What should have happened?
- As we learned more about safety, and as the regulations changed, we should keep up and always update our equipment to be as safe as we currently know how to make it.

What actually happened?
- The machine was not updated. Why not? What policies (or lack of) prevented that from happening? That is what you want to address.

As an aside, you also want to look at your other old equipment and make sure it is also updated.
11/03/2017 11:18 AM
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Christian Sampedro

Also, when you do Root Cause Analysis, the root is usually the last thing over what you have control. I don't know if you want to go as deep as Machine Design because it is likely that you don't have control over that and, at this point, probably doesn't matter.

I had a similar issue with a programming bug on a cnc. 99.9% of the time the machine will perform as required but if a collision occurred it was catastrophic. Doing Root Cause we started from the methods of operation to the programming techniques, until we found the bug. We could not fix it but at least developed a warning when the conditions for the bug to occur were met. Just keep digging but stay within your circle of influence.
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