Recurrence Prevention

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.