Category: Quality

School Lunch and Water Poisoning in India… are the Root Causes Similar?

August 5th, 2013 by

With community protests after losing school aged loved ones, the Indian Government is closing in on suspected causes to include suspects. But is this a sign of Systemic Food Quality Control or as TapRooT® calls them “Generic Causes”? Will the nature of the investigations detour looking for Generic Causes by looking for blame instead?

Read below and ask, how would this be investigated or analyzed if it were in your hometown? What would be the response of the lunch cafeterias and Food on Wheels programs for the elderly and sick?

In a months time…..

23 students in the southwestern coastal state of Goa were treated at a hospital after they got sick at lunch

23 students died and 25 people were hospitalized from food poisoning after a school lunch in northern India’s Bihar state

Schoolchildren falling sick after drinking contaminated water from hand pumps continued for the third consecutive day on Saturday with at least 35 more students taken ill in different parts of Bihar.

Arrests made in two of incidents with possible cause  being insecticide poisoning; the water pump incident possibly criminal intent and the Bahir lunch room incident due to possible negligence.  The Goa incident not so clear in details yet.

Due to fear, large lunch producers temporarily shut down their lunch kitchens resulting in children not getting their mandated free lunches during school.

See more at this link:

Consent Decree of Permanent Injunctions appear too frequent in FDA Regulated Industries, Why?

July 16th, 2013 by

Whether in the medical device, pharmaceutical or the food manufacturing industry, a company usually has had many violation corrective action chances before they get a consent decree of permanent injunction. At this point a third party reviews current deviations and often identifies a weak or non-existent root cause analysis program.


Now don’t get me wrong, this is often when our TapRooT® Root Cause Process gets recommended as a possible option and we gain a new client. However, I would prefer working with an FDA regulated company to develop effective corrective actions before they get in trouble. Or at least when they get their first FDA Finding.


Often FDA findings are found by an external audit.  To remain independent, the auditor turns over the findings through proper protocol and the company involved must provide proof that the causes were found and that the corrective action is effective. So if this protocol is followed, how did we get to a permanent injunction?  Can the repeat findings be purely an Enforcement Needs Improvement Root Cause for policies not followed?


I suggest Enforcement needs improvement is not the only problem.  To find out what your company might be missing in your RCA process. Find a course close to you and send one of your key quality or safety problem facilitators.  Here is our upcoming courses link:


To get you thinking about possible gaps in your root cause analysis program, view this presentation given at our 2012 TapRooT® Summit.


Then check out the quality track in the upcoming 2014 Summit in April.

Why Do People Have Problems Finding Root Causes? Read this Article – Under Scrutiny – from Quality Progress…

February 25th, 2013 by

Do you have problems finding the root causes of quality problems, safety incidents, or mechanical failures? It could be becuse of the root cause analysis tools you have chosen to use. Some tools have inherent weaknesses that are “built in.”

The article attached below (as first appeared in Quality Progress, the flagship magazine of the quality professional society ASQ), explains why some techniques commonly recommended for root cause analysis (like 5 Whys) will cause problems when applied by people in the field.

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(click the link above to download the article)

Once you finished reading about the limitations of 5-Whys and Cause-and-Effect, sign up to learn about the advanced root cause analysis system that was intelligently designed to avoid those problems … TapRooT®.

CLICK HERE for more information about TapRooT® (including a TV interview of Mark Paradies about root cause analysis) and HERE for information about TapRooT® Root Cause Analysis Training.

Healthcare Scandal in UK – Calls for Major Improvements in Patient Safety and Criminal Prosecution of “Wrongdoers”

February 24th, 2013 by

Here’s a link to one of many stories about the “scandal” at UK hospitals in the Midlands:

The story says that “…up to 1,200 patients are believed to have died between January 2005 and March 2009 as a result of poor care at Stafford hospital.”

Here’s a link to the Executive Summary of the report referred to in the article:

Here’s a page where you can download the entire report:

The reports are extensive and I haven’t yet been able to wade through them (many volumes and 290 recommendations).

Here’s a press conference by the Chair of the Inquiry, Robert Francis QC:

The problems reported certainly do seem shocking. The problems are obviously systemic (generic) and seem to be related to the organization. The call for culture change seems obvious, but how to change the culture will be difficult. The problem for patients is the lack of choice (there is only one NHS) so that patients can’t “vote with their feet” when the standards of care become substandard.

The popular press and political outcry is calling for increased regulation and criminal prosecution of those who violate the rules. This seems close to the standard blame game and may succeed temporarily until the increased scrutiny eventually succumbs to complacency. This seems common in organizations with a monopoly on a certain service or product.

It seems to me that competition from hospitals trying to win additional patients would be the ultimate culture change recommendation. However, it is unlikely that this approach could be taken since the UK has had a single national service for so long.

Being in the UK when the story was receiving so much press, I was constantly being asked about how one would find the root causes of patient safety relayed problems. Of course, I described how healthcare organizations in the US use TapRooT® to investigate sentinel events. In the US, patient safety is becoming a competitive advantage – a way that hospitals may compete for patients.

What does your hospital do to ensure the highest standards of patient safety? Does your root cause analysis find and fix the root causes of patient safety problems? Does your management require advanced root cause analysis and insist on the implementation of effective corrective actions to sentinel events? Can you show the improvement in patient safety through the use of advanced trending tools?

Those interested in improving patient safety should consider attending the Improving Healthcare Quality and Patient Safety Track at the 2013 Global TapRooT® Summit in Gatlinburg, TN, on March 20-22. For more Summit information see:

And for the track’s detailed schedule, see:

and click on the button on the left for the track specific schedule.

For those in the UK, changes as great as those described will be difficult and take tremendous effort. I wish you luck but advise you that thorough advanced root cause analysis and effort will be required on a continuing basis if progress is to be made.

Our Mumbai 5-Day TapRooT® Course is Scheduled for April!

January 14th, 2013 by

Based on client’s request, we have scheduled our ONLY Public India 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training for April 22 – April 26.

For those not familiar with the course, it includes the TapRooT® single user software (unless attendee’s company has a network software license), TapRoot® book, Corrective Action Helper®, Root Cause Dictionary & Laminated Root Cause Tree, Course Workbook.

Course Fee which includes a software individual license for each student is only $2,395 USD. Here is the registration link: Register

Please register 30 days prior to the course if you need a quote first to send to your billing department. Anything within 30 days or less must be paid for during registration.  All course seats must be paid for prior to the course to hold the seat and attend the course.

We look forward to seeing our repeat clients and new clients in our only 5-Day public India course for 2013.


2013 Global TapRooT® Summit Video: Improving Quality & Corrective Action Programs

December 27th, 2012 by

Take 2 minutes from your afternoon to learn from TapRooT® Instructor/ Six Sigma expert Chris Vallee. He’ll highlight what you’ll learn when you attend the Improving Quality & Corrective Action Programs track at the 2013 Global TapRooT® Summit.

Are you interested in attending our Summit? Register today!
Visit our 2013 Global TapRooT® Summit page for more information.

QMN Weekly Bulletin Reports Bad Root Cause Analysis as One of the Most Common FDA Findings

March 31st, 2012 by

A recent article about a drug manufacturer quality problem said:

Root cause analysis isn’t new, but it is one of the most often misunderstood quality processes drugmakers must master. In fact, inadequate root cause analysis is one of the FDA’s most common findings during an inspection.

It then says they can send you a booklet to learn how to perform root cause analysis.

A booklet? You must be kidding. For something as important to pharmaceutical quality, would you depend a booklet?

Why not check out the techniques used by industry leaders around the world – TapRooT®.

For public course information see:

Or drop us a note to set up a course at your site.

Root Cause Analysis Tip: Why Wait for a Problem to Use CHAP?

February 8th, 2012 by

In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course and in our TapRooT® book, TapRooT® Changing the Way the World Solves Problems, we introduce the Critical Human Action Profile (CHAP) tool to help collect more information to analyze any type of problem at the process task level.  I like to call this looking at a problem at the 1 foot level as opposed to many investigations that analyze their problems at the 100,000 mile view only.

The tip here, however, is “why wait for a problem to use CHAP?”

Identify, Evaluate and Improve before it is too late!

Using a very over simplified list of procedure steps on How to Remove a Fuel Pump, found on the internet, I would like to show you how to use CHAP proactively to improve Safety and Quality during a task.

WARNING: The steps listed in the demonstration example below on removing a fuel pump shall not be used. They are incomplete and not necessarily accurate.

Where to start? First off you already perform  JHA, AHA, JSA, Observations…. So Going Out and Looking (GOAL) should not be new or require a lot more additional resources. The difference is that you will be utilizing your resources more efficiently.

1. Start by identifying a task performed by employees that are critical to:

a. Customer/client satisfaction

b. Product Quality

c. Project Timeliness

d. Employee Safety

e. Customer Safety

f. Environmental Exposure

2. Once the task is identified, list the steps to be performed like listed in the image below.
Note: Do not forget to use the Basic Cause Category Procedure in our TapRooT® Root Cause Tree to look for missing best practices as well when listing the steps.

3. Identify each step of the task that is critical to the items listed in step 1 criteria of this article.
Which steps listed above for the fuel pump removal do you think would be listed as critical?

4. For each critical step in the task perform a CHAP Profile.

Note: For each of the items listed below, do not forget to include the Best Practices listed under the Human Engineering Basic Cause Category in our TapRooT® Root Cause Tree.

Great Human Factors: Wrong Tools, Bad Access by Design, Per “Ingenuity” or All of the Above?

January 19th, 2012 by

As an ex-aircraft mechanic and a “sometimes gotta work on my own car” mechanic, I have in the past borrowed or made some of the tools pictured below. The questions remain:

Wrong Tool?

Bad Access by Design?

Mechanic’s Ingenuity?

Or a little bit of them all?

Finally, ever have one of your modified tools bite you back?  Share your stories in the comment section.



Oil Cooler Line Wrench #2 009 (Medium)

Summit Week Quality and Corrective Action Programs Best Practices Track

January 11th, 2012 by

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Karen Migliaccio has done a tremendous job setting up this first TapRooT® Summit Quality Track. From cross industry representatives to demonstrating field successes all the way up to company process changes, you will find this Summit Week Track interesting and applicable.


TapRooT®; Implementation Success Stories:

Successful Implementation of TapRooT® at Steris (Kevin McManus)

High Quality TapRooT® Implementation (Dennis Osmer)

Using the Baldrige Criteria to Achieve Performance Improvement (Kevin McManus)

Root Cause Analysis of Quality Problems:

Challenges in Biotech Quality Root Cause Analysis (Michael Gorman)

Root Cause Analysis of Incidents Occurring in the Pharmaceutical

Industry (Debbie Riley)


CAPA in Quality: The Strong and the Weak (Karen Migliaccio)

Quality Issues:

Quality Initiatives That Lead To Continuous Improvement Efforts (Bryan


Using a Quality Plan to Drive Improvement (Zena Kaufman)

The 7 Secrets of Incident Investigation & Root Cause Analysis (Mark Paradies)

Designing Your Continuous Improvement Program (Kevin McManus)


How Pfizer Achieves Operational Excellence (Gerry Migliaccio)

Planning Your Improvements

To read more about each session see:

Then select the Quality and Corrective Action Programs Track.

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But there’s more!

Before the Summit we have a special nTapRooT® Root Cause Analysis Course focused on finding the root causes of quality issues.

When you attend both the pre-Summit course and the Summit, you save $200 off the course fee.

Just click on the link below for more information…

TapRooT® Quality/Six Sigma/Lean
Advanced Root Cause Analysis Training

Root Cause Analysis Tip: What Can Go Inside the Event Shape when Mapping out your SnapCharT®?

December 14th, 2011 by

Whether doing it by hand or in our TapRooT® Software, what can go into the Rectangles that we call Events (Who did whats or what did whats that occurred during the timeline that you are investigating)?



Who s:

Actions by the Operator, Mechanic, Manager, Vendor, Supplier, Contractor, Technician, Customer Service Rep, Engineer, Designer, Nurse, Doctor … as you can see the list is unlimited but understanding the who (we use job titles only) helps us to see if the who was setup for success prior or during the action he/she performed.


Caution ( … this may not be what you expected or have been doing)

Equipment Actions: Relay opened when energized, Butterfly valve stuck shut, I.V. bag port become blocked with debris, fuel gravity fed into container through piping …

Hint: If working with equipment, pull up the equipment and system functional diagram up immediately to help you map out the Events.

Chemical Process Actions: Catalysts heated up, hot mix heated up …

Transactional Process: Purchased order received by customer service, SAP sent late warning to warranty …

Hint: Yes, you can follow a piece a paper, hazardous material shipment.. that is handed off from person to person just like you would a person.

Hopefully, this should open up your investigation options even more! By the way, I even mapped out the actions of a horse and a monkey which was analayzed under Human Engineering.

Aurobindo Pharma taking their Root Cause Analysis to World Class Standards

December 13th, 2011 by

For any successful process improvement implementation, Senior Leadership support and actual presence is necessary. Aurobindo Pharma’s Leadership presence in the early stages of the course and the questions that they asked their students directly is a clear indication that this first team of investigators have full support and expectations set.

Second requirement for success is to have cross utilization during investigations and learning between departments. From the lab, materials, shipping to QA, there was complete and thorough team building.

Finally, the Senior Leadership set expectations and future growth opportunities to include future training and possible multi-user intranet based software licensing. Based on building successes and return on investment.

It was a pleasure to teach and work with this group personally in Hyderabad, India.

If you have to perform Root Cause Analysis for regulatory, equipment and safety issues in India, but are not able to set up an onsite course like the Leaders of Aurobindo Pharma did, I suggest you go to your leadership and get commitment to attend the upcoming Mumbai 2-Day course in February.  Seats fill up fast and getting funds authorized may take time so do not delay if you are ready to go World Class with your peers.

Go here to register for the 2-day

See the public courses and root cause articles for India:

India Information Technology (IT) and TapRooT® Software Developers all in one room? If close to India, Here is Your Invite!

August 24th, 2011 by

When you need TapRooT® Root Cause Analysis Software implementation advice or have other technical IT needs, who do you call? Easy… our clients call 1.865.539.2139 and ask for Steve, Zach or Dan. When the IT experts here or at your place of business need help, what do they do for help? Simple, they map out the issue using TapRooT®’s SnapCharT® first and then find out where the equipment or human performance difficulty issue needs to be addressed.

Why tell you all this today you may ask? Because Dan Verlinde, Director of Information Technology & Software Development, and several U.S based and India based software developers will be attending our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in New Delhi this September.

New Delhi, India Sep 5 – Sep 9 Register

If you are the IT TapRooT® Software Lead based in or Near New Delhi, sign up for the September course before it is too late.

Root Cause Analysis Tip: Measurements … "Smeasurements"! Who Needs Them?

July 13th, 2011 by

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If today was Wednesday … what measurements (metrics) could be used to describe it:

1. There are 52 Wednesdays in the Calendar Year of 2012.

2. There were 53 Wednesdays in the Calendar Year of 1873.

3. Wednesdays make up 14% of the Days of a Calendar Year.

4. There are 9 letters in the word Wednesday: 2 e’s, 1 w, 2 d’s, 1 s, 1 n, 1 a and 1 y to be exact.

5. There are two syllables in the word Wednesday.

The point of my number parade? Simple, we can measure anything … but does it provide value or predictability? Are the numbers representative of what one is truly trying to measure?

In the Changing the Way the World Solves Problems book provided to all our TapRooT® students, there is a section titled A Guide to Improving the Use of TapRooT®. The tip today from this guide focuses on Topic 1: Measurements. With the first question being, has your company agreed on a reliable measurement system?

Why a measurement system and not standalone metrics that represent individual problems in individual departments? The answer is because no one person or one department works in true isolation. Measurements of money savings, defect reductions, tool repair or tool selection reported by one department may actually cause an increase of those measurements in another department. So no actual money saved for the company!

Developing a Reliable Measurement System starts with the developing and defining the fundamental components and rules for your company. I caution against generic one-fits all Systems developed outside of your company.


Measurement: An observable (observed either by human or equipment) behavior (behavior of equipment, people or process) that can be measured quantitatively or qualitatively.

Rules for Measurements:

  1. Only used to measure for what it was intended to measure. Nothing worse than using someone else’s numbers for your own needs just to find out it does not measure what you thought it did.
  2. Collected and Documented using the same method with the same types of tools (equipment, forms). Not sure of the consistency of your measurement collection process? Perform a Measurement System Analysis (MSA) on it.

Types Measurements (Just to mention a few):

  • Operation
  • Production
  • Human Resources
  • Safety
  • Customer
  • Warranty
  • Financial (Fringe or Burdened)
  • Maintainability and Reliability
  • Regulatory
  • Direct or Indirect Labor/Costs

Purpose for Measurements:

  1. Predictive Indicator- Can tell you what could happen before it happens. Note: No predictor is 100% correct but many are very reliable.
  2. Lagging Indicator- Too late! Good or bad news, it already happened but it is a necessary to know. Note that some Lagging indicators can be a leading indicator for another lagging indicator. For example, an increase in near misses can be a predictor of a severe incident if not corrected.

Measurement System: A system allows good measurements to produce good indicators. Of course it also allows junk in junk out, even with the best system in place. So to help define what a measurement system is or could be, answer these questions:

  1. Based on the measurements input, can you see the company “big picture” and can you then break down these indicators to their lowest input level?
  2. Are reports and graphs pulled from one central location to prevent duplication?
  3. Are measurements pulled from the same set of numbers to increase consistent trending?
  4. Is the system audited for consistency and accuracy?

Seems like a lot to make sure you know where your company is going and where it has been doesn’t it? Did I also tell you that you should also be able to translate all measurement indicators into company production and operation dollars? As the our book says, “dollars are the language and measuring stick of management.”

If this post gets you to think … “Why does this make so much sense and why did I not think of this before with the same perspective”?

If the answer is yes, then I have some options for you that appear once a year in a public setting this February:

Advanced Trending Techniques
TapRooT® Quality/Six Sigma/Lean Advanced Root Cause Analysis Training


Chris Vallee joined System Improvements in 2007 and is a Senior Associate, TapRooT® Instructor, and Investigation Facilitator.

Root Cause Analysis Tip: You Know How to Perform a TapRooT® RCA but Where Do You Target Your Resources?

June 29th, 2011 by

Let’s be honest, all companies want a good Return on Investment (ROI) on any investment. This is exactly why Mark Paradies and Linda Unger provide a section in our TapRooT®, Changing the Way the World Solves Problems book titled A Guide to Improving the Use of TapRooT®. The tip today focuses on Topic 2: Target Selection.

If you have set up good metrics to measure, you can start by looking for your Top Drivers in a Pareto Chart. The idea is that if 80% of your issues are caused by or correlated to 20% of a sampled set of categories, then start there first for more ROI. Review the Chart below and then read the cautions below:


1. “Never Ever Ever” define a category as “Miscellaneous” or “Other”! I promise you that it will always be in the Top Three every time.

2. When it comes to the y-Axis on the Chart, do not just use Cost as a measurement, also use Risk and Frequency. One near miss may not have cost any money but it could have killed someone. If you look at Cost or Frequency only, this would not show up as a Top Driver.


Another Quick Way to decide where to Target your resources is to use a Plot Map. Read more here as to how this map reduced illnesses from the water supply in certain areas.


Finally you may want to measure how accurate and precise your improvements have been. In earlier trending articles  we introduced the Process Behavior Chart. Below is one more example of how to measure Risk Reduction using a scatter and bulls-eye chart.
Here is a quick description on what the charts represent:

1. The Center (Bulls-Eye) of the chart represents that the risk targeted has been eliminated.

2. Each subsequent ring of the target indicates risk mitigation at lower levels (the outside rings do show risk mitigation but not as strong as the inner rings).

3. The dots indicate the actual risk level mitigated for each RCA performed with corrective actions implemented and verified for effectiveness (sounds like SMARTER technique from class don’t it?).

Looking at charts above, which two Charts would you be happy with and why?

To find out where to receive hands on training for the next TapRooT® Trending Course look here:

Root Cause Analysis Tip: Trending your Trending Program … a Love-Hate Relationship with Numbers

June 1st, 2011 by

I often hear, “We trend lots of issues … see all the numbers and charts?” Heck, I have even said it myself a few times in my life. Then we go and check our “numbers” ask, “what does it show us today?” Or even worse, the boss asks, “can you show me ……….. ?”

Here are some of the reactive action items that I have had to follow up on in order to try and answer a question for someone else:

1. “Everything was just fine and now things seem to be out of control; show me where it went wrong?”

2. “After starting YOUR new metric, things really got bad, why?”

3. “Looking at both of these charts, show me the correlation.”

4. “But we have only had 5 incidents in 5 years (infrequent data), how can we trend that?”

5. “Look at these great trends … , what did WE… I mean  you change?”

As I started this post, this article appeared in the news discussing the Numbers Game:

Just because we’ve seen an increase in the number of tornadoes doesn’t mean there has actually been an increase in the number of tornadoes,” said Greg Carbin, the warning coordination meteorologist with the Storm Prediction Center in Norman, Okla.

Decades ago, when the country was more sparsely populated — and not everyone had a camera-equipped cell phone — there were simply fewer people around to spot and report tornadoes, Carbin said.

In addition, Carbin said, many initial tornado tallies include tornadoes that are counted more than once.

According to NOAA’s preliminary count, April saw 875 tornadoes. “That’s a gigantic number,” Carbin said. “It may turn out there were that many tornadoes, but I can guarantee that many of those were not significant tornadoes, but they get into the database now because everyone has a tornado they want to report.”

The highest number of tornadoes on record for any month is 542, from May 2003. Carbin said he suspects that once all the data are compiled, April’s numbers will be closer to the May 2003 numbers.

In addition, both Carbin and Crouch pointed to the fact that with increasing urbanization, more people are affected when storms do hit, putting tornadoes in the spotlight.

Numbers and climate conditions aside, one thing is for certain, the scientists said — this tornado season has been unusually violent, as the horrific images splashed across the evening news attest, and it’s not even close to being over.

But it is not hopeless, I promise. The first step is to back out of your numbers and ask:

1. Where did these numbers come from?

2. What were the numbers originally designed to measure?

3. Are these numbers part of the same set of behaviors and tasks or are they independent?

4. Were the numbers created with limited bias and not driven by a reward or discipline factor?

5. Are these numbers occurring frequently or is this intermittent and infrequent data?

6. Finally, do you understand your numbers and does the boss know what the numbers mean when you show the charts and trends or lack of trends?

Does this mean I think you need to go back to school for six weeks of statistics … no!

Does this mean that you need to throw all your old numbers away and start from scratch … maybe!

Does this mean that you may need a couple of days to reassess what you use and how you use it to trend … yes!

Since two days is not too much out of a busy schedule there are three resources that can help in you in your love-hate relationship with trending and metrics:

1. Read Chapter 5 in the TapRooT® book, TapRooT®, Changing the Way the World Solves Problems by Mark Paradies and Linda Unger

2. Read the Making Sense of Data by Donald Wheeler

3. Attend our upcoming Advanced Trending Techniques course where you receive the Making Sense of Data book, Course Workbook and hands on exercises taught by experts in the field who use real world applicable trending.

Monday Accident and Lessons Learned: Good or Bad Quality Root Cause Analysis?

February 21st, 2011 by

This is more of a quality problem example rather than the typical Monday Accident article. It starts with an example of root cause analysis in an old video from the Juran Institute …

Now apply your analytical skills … Is this a good job or a bad job of root cause analysis?

Now read this article that I wrote for Quality Progress titled, Under Scrutiny, posted here:

You don’t need to be a member of ASQ to read the article, just register to see the open access article.

Now you can understand why I don’t think the 5-Whys helped them find root causes. Rather, all it did was help them explain the knowledge they already had.

Suitcase Story Part II

February 8th, 2011 by

Interesting twist this morning …

The airline called me at the hotel and asked if I wanted my suitcase delivered or did I want to come over to pick it up.

I told them they already delivered it the night before.

At that, the person from the airline seemed confused. They had already delivered it?

“Yes,” I told him, “The night before.”

He apologized and said that someone must have made a mistake.

I didn’t say it but … Yes they did! Several mistakes by now.

Maybe now it is time to start a root cause analysis?

Ahhhh … All’s well that ends well. Why bother.

Bag Lost – Root Cause Analysis Opportunity? NO – More like ZERO Quality Improvement.

February 7th, 2011 by

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I few from Milan to Amsterdam yesterday.

It was a direct flight.

I got to the airport and checked in with 4 hours to spare.

The plane was lightly loaded.

Then, we had a 1 hour 30 minute gate hold due to weather because it was windy in Amsterdam (such is modern air travel).

We arrive 90 minutes late.

Now the bad part.

When I arrived in Amsterdam my bag didn’t come out.

I waited for a while to make sure it wasn’t the last one. 20 minutes slipped by.

I always stand near where the bags come out to make sure that nobody mistakenly takes mine. (I’ve stopped this from happening twice in my flying career.) I know my bag never came out.

Then I went to get in line to report the problem. There were about 50 people ahead of me. Another hour slips away.

I finally saw a person. They thought … it can’t be lost. It must have gone to the transfer station or perhaps one of the places where bags fall off the line. Or maybe you didn’t wait long enough. I’ll have some people check. I started filling out the paperwork while they searched. 30 more minutes slipped away from my life.

They also checked the computer. No note that any bag failed to make the plane. (Isn’t it part of modern airline security to make sure that your bag flies with you?) No note on the computer. It must be in Amsterdam – let’s check all the usual suspects again. 15 more minutes slip by.

Finally, they decide it is lost. They accept the form and tell me it will probably be on the next flight. They’ll bring it right over to my hotel when they get it and leave it at the front desk and tell them not to wake me if it comes in tonight late.

I think, “It is already late.”

“When is the next flight?”, I asked? They replied, “I’ll have to check.” … “Sorry – not until tomorrow, 9 AM. But we will update the bag status on-line (the internet!) as soon as we know anything and that will automatically text your cell phone.”

I check the baggage loop one more time on my way to customs. No bag.

The next morning I went to breakfast and checked with the front desk. No bag yet. And no text message.

After breakfast I decided to check the bag status on-line. Bag status was “unknown.” But there is a reassuring note that if your bag status is still unknown after four days, there is a special phone number to call. I begin to wonder … “If they have a special number, how many bags are never found?” I remember the 60 minutes story about the cavernous warehouse in Alabama for lost bags.

I decide it’s a good time to call the regular phone number and see what they say.

They check their system. Good news. The bag is scheduled for the 4 PM flight. I wonder, what happened to the 9 AM flight? What if I really needed my cloths? What if I was departing on a cruise or on to another international location?

I wait and hope.

By 7 PM, the bellman finally brings my bag to my room. That’s almost exactly 24 hours after we were suppose to land.

I was going over this in my head and thought …

This is a root cause analysis opportunity!


1. First … Think of the time wasted.

a. Over two hours of my time was spent just reporting the lost bag.

b. Some unknown amount of airline employee time was spent  dealing with me, looking where bags could get lost (is says something that they know places to look), filling out paperwork, updating computer records, dealing with my call, and getting the bag delivered.

2. Second, I went a day without a bag. This could have been a minor disaster. Even though it wasn’t a disaster, it did leave me an unhappy customer. How many other unhappy customers like me are they creating every day?

Luckily, I travel prepared. This preparation is because I EXPECT them to lose my bag. This is a normal part of the frustration of flying. One more reason people drive if the trip is short. (I actually was thinking about a train trip from Milan to Amsterdam. I could have made it faster than my bag did flying.)

3. Third, is this a security violation? If making sure that the passengers bag travel with the passenger is a part of modern security, certainly this is a security failure.

Imagine how many future problems could be avoided if they started treating every lost bag as a customer service incident that needed to be investigated and reported to the CEO? I bet in a mater of weeks, or perhaps months, the number of  “lost” bags for no good reason (like mine) would be ZERO.

The few remaining lost bags due to really tight gate connections (yes, people can run faster than bags can be delivered) would be be a very managible number and even those might be reduced.

What problem could they work on next?

What about delayed flights? Alaska Airlines did this and showed major improvements!

Bagage damage?

Plane damage?

Worker injuries?

Weather related delays?

Air traffic delays?

Security errors?

Long lines at the baggage counter?

Long lines at the ticket counter?

Slow baggage delivery?

All of these are fixable problems. They need advanced root cause analysis (not just stupid 5-Whys.)  I’d bet many could be eliminated or at least dramatically improved at a low cost. And some might require some dollars to fix – but at what potential cost savings in the future?

Some could become a competitive advantage for a particular airline.

Others might improve the whole air travel experience.

Wow! Imagine the progress that could be made.

Root cause analysis is NOT just reserved for when planes fall out of the sky.

If only the airlines were interested in customer service!

Because no one is investigating this incident, flight delays, weather delays, air traffic delays … All these problems are just part of the fatiguing process of modern aviation. Which continues to get worse (a little more inconvenient all the time).

It will be no better when I fly out on Friday than when I flew in on Sunday.

ZERO quality improvement.

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Please correct me if I’m wrong about this …

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