Recurrence Prevention
Updated: Aug 29, 2020
What is “Recurrence Prevention Measures
Preventing a recurrence is to never repeat a failure that occurs for the same reason. Therefore, it is necessary to investigate the cause thoroughly and remove the cause.
A cause is not a superficial cause which can find on the surface,
but an underlying factor (root cause) which is in hiding in the in-depth.
In most cases, the root cause is not a person, but it lurks in the elements that constituting the system, such as structure, mechanism, system, and procedure.
A human error is just a trigger. The system is required to prevent a mistake
even if a person makes a mistake
"Once a failure has occurred, it is necessary to look back not only the technical side but also the work process. Investigate the cause where it came from in the work process"
Content of Recurrence Prevention
i) Countermeasure(C/M) & Recurrence Prevention(RP)
ii) Basic procedures of Recurrence Prevention
Step-1. Record of orders, developments, and preparation works
Step-2. Identification of problems
a) Reflection
b) Process Analysis
Step-3. Investigation of Root Cause
Step-4. How to plan Recurrence Prevention Measures
Step-5. Standardization and expand to related departments
I) Countermeasure(C/M) & Recurrence Prevention(RP)
Defect Measure
Recurrence Prevention
Treat the failure as a treasure & turn the failure into a valuable lesson
ii) Basic procedures of Recurrence Prevention
Reflection
① Narrow down the work should be improved
Process Analysis-
② Identify the issue of work to improve at the process
Why-Why analysis
Step-1. Record of orders, developments, and preparation works
Daily work records should be maintained because without records it is very difficult
to look back.
Step-2. Identification of problems
a) Reflection
b) Process Analysis
2.1 What is Reflection-
Visualization & reflect the sequence of events which took place during
past activity based on facts to identify the problems
2.1.1 Identification of problems(Reflection)
Ex.:Drawing, Assembling drawing, Spec sheet, report, meeting minutes, etc.
1) To identify the problem from the work process / systemic point of view, it is very important to respect the facts (=evidence) without subjective impression/guess.
2) Visualization of whole activity by all related persons(Procedure③),
prepare the goods for face to face mtg.
2.2 what is process analysis-
Sub-divide the process into detailed processes
Clarify the process that caused occurrence/flow out and define the problem
Step-3. Investigation of Root Cause
investigate the Root Cause by digging out the work process / systemic problems and weaknesses of your work.
3.1-Procedure of root cause investigation
(1) Define viewpoints of Why Analysis
(2) Identify causes
(3) Identify the Root Cause
Step-4. How to plan Recurrence Prevention Measures
The step for each Root Cause identified in Why Analysis, plan the RP Measure
Required Output for RP Measures
The RP Measure for the Root Causes must be able to be carried out without fail
and must be sustainable and also, must fulfill the following conditions.
1) Against the Root Causes, The new/revised work process must be specific, practicable, and sustainable (including the tools, information/judgment criteria required in the process).
2) The members who are / could be assigned to the work process must be able to
judge the quality of their work by themselves
Step-5. Standardization and expand to related departments
・ Incorporate the necessary work into the standard work procedures
・ Incorporate the background and heart from the knowledge of “why to do so” into the
standard.
・ Proceed as the standard and improve and change it if there are any problems.