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Does root cause always end up in management?
Does root cause always end up in management?...cant find a tool...tool not put where supposed to be...person using tool did not put back...was not trained to put did not assess risk of tool not being put back therefore did not make a training, sign out sheet, end of shift tool return policy etc..

Diameter oversize...did not read dro correctly...dro led was flickering on and off...maintainance program not in fault.

Part fell off siderails on not assessed on policy to always have fault.

In theory, our staff is to follow procedures written and approved by top management. If they move outside of procedure, why was there not something in place to prevent? management fault. I can go on and on, how far does a rca go? if taken far enough it always seems to go back to management and risk assesment for safety, training, poka yoke etc. Am i at fault for all non conformities lol. Why is my name not on NCRs lol. If so.....the owner of the company failed to asses the risk of the quality manager not knowing and being trained thoroughly and failed to provide or expect said training.....Years ago i was on vacation in new mexico. Not at work for 2 weeks. During my time off an order of parts were killed on a lathe. I got back assessed the situation, found the issue and resolved it through tooling and inspection processes. CEO told me it was my fault for not assessing the risk prior to me leaving, it was my written procedures that failed. The guy running the parts used the wrong tooling insert, did not check the insert, and did not get the parts inspected. MY FAULT lol. You can lead a horse to water but you cannot make him drink. "I wasn't told to do that" At what point do we hold the process owners responsible instead of blaming management for poor procedures. We can write a procedure for how to write a procedure. Procedure on how to hold a company safety meeting. Procedure for eating lunch in the cafeteria. But it all boils down to someone doing THEIR job and taking ownership of the process and its outcomes.
according to Deming, should end up there at least 80% of the time...
Pareto 80/20. get rid of management....80% of root cause gone.....
Existence is the root cause of everything.   Tongue
In my opinion, not everything needs to be in writing. It depends on many factors: Employee experience, size of business, employee turnaround, etc.... That being said, it appears to be a training issue for the people who were supposed to take over from you. Was this employee properly trained? Most likely not. Even if your procedures did specify what to do step by step, i am not sure your replacement would have consulted the document. Anyways, i see that training and perhaps improved instructions would complement each other to avoid this in the future. Whoever assigned this employee to do your work without proper training is at fault. So yeap, it does appear to fall on management.
Every organization needs to begin with defining the training needs for each employee. Hoping it gets done is bad management.

IME, many managers tend to trust their beliefs over information. How did they become managers if they were not so smart, right?!??!

There are bad auditors out there, I am sad to say. Bad NC's often lead to the minimization of system documentation, so that there is no conflict between the say what you do and do as you say. The quest to avoid NC's in this manner is a recipe to lose control.

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