Investigating major quality problems can be a difficult task. I think I speak for most workers; people don’t like to ‘get in trouble’, especially on the job. Whether negligence is involved or not, gathering useful information can be a challenge. However, in order to correct the situation and prevent it from happening again, it is extremely important to determine exactly what happened.
In my experience, the success of an investigation usually depends upon the investigator’s ability to put workers at ease. This helps the process to move quickly and thoroughly, resulting in accurate identification of the problems and rapid resolution.
Dale Carnegie recommends listening first, particularly in a tense situation.
“Let them finish. Do not resist, defend or debate. This only raises barriers. Try to build bridges of understanding. Dale Carnegie – Goodreads.com link
When trying to solve a serious problem, getting the full story with as much detail as possible is very important. Channeling Mr. Carnegie’s term, always attempt to “…build bridges of understanding”.
The three steps below are useful in the initial stages of the investigation
- Preface the discussions with the people involved
- Let the interviewee know that all information is helpful toward resolving the issue completely.
- Help them understand they are part of the solution, not part of the problem.
- Make the discussion as non-emotional as possible. Let the person being interviewed know that the discussion is strictly intended for gathering facts and not meant to find someone to blame for the issue.
- Mention that it is very seldom a single act or situation that caused the problem and their input is needed to be able to assemble the ‘pieces of the puzzle’ to resolve the issue once and for all.
- Establish the timeline based on facts
- When did the situation occur?
- What equipment or process was involved?
- Explore any unusual circumstances taking place at the time of the incident.
- Who else would have been in the area when the problem occurred that could add more information?
- If the interview process uncovers multiple sources of the problem, collate all of the information into a single timeline listing all of the discrete times, places, and people involved in the issue.
- Once the basic causes are worked out set up a meeting with the appropriate personnel to perform a root cause analysis (to be discussed in Part 2).
Over 15 years ago I had a situation where I used the steps above to gather critical information necessary to resolve a complicated quality issue. A third party manufactured a finished product for our company and unfortunately the product was contaminated with an undeclared allergen. This was an extremely dangerous situation for someone who was highly allergic to the material, and a nationwide recall was performed. Thankfully nobody was ever injured as a result of this issue.
Immediately after the discovery of the problem (and a separate team had quickly initiated the recall), I was sent to the manufacturer to determine what happened and implement new procedures to prevent it from happening again. From the very beginning it was clear that this investigation was going to be challenging. From a practical perspective it was going to be costly; the situation would most likely result in a major insurance settlement (best case) or a significant legal proceeding (worst case).
The first thing I did was schedule a meeting with the owner at the company. The purpose of the meeting was to lay out the intent of my visit and the expected outcomes. In this case, it seemed straight-forward: determine exactly what happened and establish new procedures that would prevent it from happening again. I made it clear that my focus was on determining the root cause without assigning blame. I also made it clear that the information gathered during the investigation would be shared with the owner prior to communicating it to my management. I wanted the owner to agree that the information being communicated was factual and unbiased before it was distributed to anyone else.
I believe by establishing these ‘ground rules’ up front, it helped the owner to feel more comfortable disclosing all of the facts. He also encouraged his employees to fully cooperate in the investigation by saying that all information would be important in resolving the issue.
The interview process took place and a comprehensive timeline was developed. With this information we were able to initiate a successful root cause analysis and determine exactly how the product was contaminated. I will describe the root cause analysis process and ultimate resolution to the problem in Part 2.
Establishing open communication, ground rules, and transparency at the start, was key to expediting a successful investigation. This enabled us to ‘build bridges of understanding’.
Look to Part 2 for the results of the interviews, the root cause process and how we worked together to correct the situation permanently.
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