The same mistake happening again is not acceptable.
There are many well established techniques for preventing the same mistake happening again. I like the sites below. Remember these key points
- Processes fail, not people.
- back to standard fixes are just fire fighting. e.g. fix a puncture
- improving the standard is what you want. e.g. puncture proof tyres, new route with less debris.
The 3Cs - Cause, Concern, Corrective actions 5W - Five whys
http://www.panview.nl/en/lean-production-lean-toolbox/practical-problem-solving-3c-5w
https://en.wikipedia.org/wiki/5_Whys
Fish tail Diagrams (Ishikawa Diagram)
https://en.wikipedia.org/wiki/Ishikawa_diagram
These can be really good when more than one contributing factor is present.
Finding waste
http://www.panview.nl/en/lean-production-toyota-3m-model/finding-muda-waste-your-process
The more steps you have, the more processes, the more opportunity for failure. Remove the waste, make your processes lean and there is less opportunity for failure to occur.
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