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Fix the root cause, not the symptom.

5-Why analysis, Pareto charts, and corrective action tracking. Solve problems permanently. Stop the same issues from coming back.

PE film instead of PP on Line 4 Open Closed
Doc No. RCCA-0042
Source QA-0015
Priority High
Leader Sarah Mitchell
Due Nov 30, 2026
Product PP Laminate Film
Problem Description
PE film used instead of PP laminate on Line 4. 500 units affected across Lots #PK-4417 and #PK-4418.
Fishbone Analysis
Problem Man Method Material Measurement Machine Environment No verification Labels unchecked Identical reels No inline test Accepts both reels
5-Why Analysis
1
PE film on Line 4? The operator took the reel that looked right.
2
Why that reel? PE and PP reels look the same.
3
Look the same? Only a small label tells them apart.
4
Not caught? Nothing checks the film at changeover.
5
No check? The changeover standard never asked for one.
Root Cause
No check of the film type at changeover, and reels that differ only by the label.
Corrective Action
Barcode scan of the film at changeover, Line 4. Lots PK-4417 / PK-4418 quarantined.
Preventive Action
Film check in the changeover standard. Color-coded PE and PP reels from the supplier.
Identify
Analyze
Correct
Prevent

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The same problems kept returning

You fixed it last month. And the month before that. The corrective action was "retrain the operator" and everyone moved on. But the problem came back, because nobody dug deep enough to find the real cause.

Now problems stay solved

5-Why, fishbone and Pareto in TeamGuru take teams past the first answer to the cause they can actually fix. Each root cause gets corrective and preventive actions with an owner and a due date. A follow-up with its own due date checks that the fix held.

5-Why and fishbone in one place
Pareto shows what matters most
Corrective and preventive actions
Follow-up with a due date

A root cause analysis in TeamGuru

The same reel of film, from a PPM spike to a fix that held

The quality alert stopped the damage: lots blocked, stock sorted at Norvik. But 500 wrong parts pushed customer PPM at Torrance far over plan, and a blocked lot does not stop the next wrong reel. That is the job of the RCCA. Here is how the plant finds the cause in TeamGuru, fixes it and comes back two months later to check it held.

  1. 1

    Start from the alert and the number it hit

    Initiate RCCA on the quality alert opens the analysis with the title carried over and the two documents linked. The team links the KPI the problem hit, and its chart sits in the problem statement: customer PPM at Torrance, September far over plan.

    Initiated from quality alert
    QA-0015 · PE film instead of PP on Line 4
    RCCA
    Doc No.
    RCCA-0042
    Title
    PE film instead of PP on Line 4
    Problem Type
    Wrong material
    Severity
    High
    Responsible
    S. Mitchell
    Relates to
    Customer PPM / Torrance
    Customer PPM / Torrance Actual Plan 50
    38
    Apr
    42
    May
    35
    Jun
    41
    Jul
    37
    Aug
    212
    Sep
  2. 2

    Look in six directions before you blame the operator

    The fishbone takes the team through man, method, material, machine, measurement and environment. The strongest branch goes into a 5-Why until the answer is something you can change. The root cause summary says it in one sentence.

    Fishbone analysis
    PE film on Line 4
    Man
    Took the reel that looked right
    Method
    No film check at changeover
    Material
    PE and PP reels look alike
    Measurement
    No inline film test
    Machine
    Runs either film
    Environment
    Reels stored side by side
    5 Why analysis
    1. Why? 1 PE film went on Line 4 instead of PP.
    2. Why? 2 The operator took the reel that looked right.
    3. Why? 3 PE and PP reels look the same.
    4. Why? 4 Only a small label tells them apart.
    5. Why? 5 Nothing checks the film at changeover.
    Root cause summary: No check of the film type at changeover, and reels that differ only by the label.
  3. 3

    Pareto shows how big it really is

    A Pareto of the quarter's customer PPM sits in the same analysis. Wrong material is the tallest bar, ahead of damage and labels. So the fix goes to every line that changes film, not just Line 4.

    Customer PPM by reject type, Q3
    58
    19
    11
    6
    3
    Wrong material Damage Label Dimension Surface
    Wrong material: 60 % of the quarter's customer PPM.
  4. 4

    Every fix has a name and a date

    Containment already ran in the alert. Here go the corrective and preventive actions, each with an owner, a due date and a percent done. The Gantt shows them side by side, and a missed due date turns red.

    Immediate actions

    Done in QA-0015: lots blocked, stock sorted at Norvik.

    Corrective / Preventive Actions
    Action Due Done
    • Barcode scan of the film at changeover, Line 4 Responsible: J. Chen 9/22 100 %
    • Add the film check to the changeover standard Responsible: M. Turner 9/29 100 %
    • Color-coded PE and PP reels from the supplier Responsible: K. Adams 10/6 60 %
    • Barcode scan on all six lines Responsible: J. Chen 11/3 30 %
  5. 5

    Two months later, someone checks it held

    Verification and follow-up has its own due date. The team puts the same PPM chart next to the fix: October and November back under plan. Lessons learned records where else the fix applies.

    Verification and Follow Up Due 11/30
    Customer PPM / Torrance Plan 50
    41
    Jul
    37
    Aug
    212
    Sep
    44
    Oct
    31
    Nov
    Verification
    Under plan for two months since the scan went live. No wrong film at changeover.
    Lessons learned
    Barcode scan now on all six lines. Label reels get the same check at changeover.

What you get

Structured 5-Why analysis

Ask "why" step by step until you reach a cause you can fix. For problems with many possible causes, the fishbone sits right next to it.

Pareto prioritization

Pareto charts show which problem categories contribute most to quality issues, so your team puts its limited time where it matters.

Corrective and preventive actions

For each root cause you set corrective actions (fix this instance) and preventive actions (prevent recurrence), each with an owner and a due date. Both are tracked to completion.

Verification and follow-up

Every RCCA has a verification and follow-up section with its own due date. Someone comes back to check the fix worked, instead of closing the problem and moving on.

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Everything connects.

Root Cause & Actions works on its own. Connected to the rest of TeamGuru it does more: every module below runs on the same platform, with one login.

Common questions

How does the 5-Why work in TeamGuru? +
You write the problem, ask "why", record the answer and repeat until you reach a cause you can act on. It sits in the RCCA document next to the fishbone and Pareto, so the whole analysis stays in one place.
Can we use Ishikawa (fishbone) diagrams? +
Yes. The fishbone is one of the analysis tools inside RCCA: you fill it in there, next to 5-Why and Pareto, and the causes it surfaces become corrective actions with an owner and a date.
How do we make sure corrective actions actually work? +
Every RCCA has a verification and follow-up section with its own due date. When the actions are done, someone still has to come back and check that the fix held, so the problem does not get closed and forgotten.
Can we link multiple incidents to the same root cause? +
Yes. When a new incident has the same root cause as a previous one, you can link them together. This also surfaces when a supposedly "solved" problem keeps recurring.
Who can initiate a root cause analysis? +
Any team member can start an RCCA. From a quality alert, the Initiate RCCA button creates one linked to the alert. Nothing starts automatically: a person decides the problem needs a root cause analysis.

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