Global Community

A few years ago, while working in the quality department at a well-known beverage company, I received a call from an upset customer who was struggling to open her drink. Hearing how disappointed she was made me take it personally she just wanted to enjoy her drink, and the packaging was standing in her way.

When I reported the complaint, my manager advised me to notify the plant and follow up. However, because the plant dismissed it as an "isolated issue," I decided to take matters into my own hands. The very next day, I drove two hours from the corporate office to the manufacturing plant to conduct an investigation myself.

Unannounced, I stepped onto the production floor to observe the daily operations firsthand a classic Gemba walk approach. Within two hours of observing a shift and line change, I spotted the issue: operators were using identical capping settings for different bottle types.

Sometimes finding a root cause doesn't require overthinking; you simply need to observe the process closely, and the real problem will reveal itself.

My next challenge was telling the plant manager to stop production. As any quality professional knows, stopping a production line is never an easy conversation. However, it was entirely necessary. We fixed an issue the team didn't even know existed, proving that a problem is hidden until it impacts the customer.

Have you ever faced a situation like this? What did you find?

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Frank Higley-Sanchez
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Isolated issue is the phrase that makes me look harder. When I sample a complaint on an audit that was closed as a one off, I ask what was checked before that conclusion was reached, and most of the time the honest answer is nothing, because the label was used to close the record rather than being the result of an investigation. Your changeover finding shows why: a defect that only appears on certain combinations looks random from a desk and obvious on the floor.

The part of your story I would underline is the stop. Plenty of people find the cause, far fewer are willing to have that conversation with a plant manager, and whether that call is backed afterwards tells you more about the quality culture than anything written in the manual.

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Dilawar Laghari
Auditor, Consultant and Trainer
Audit Workshop
https://auditworkshop.com/
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Great example, Frank. It clearly demonstrates the value of Gemba and the principle that quality must be verified where the process actually happens, not only through reports or assumptions.

What stands out is the connection between customer feedback and process investigation. The "isolated issue" became a systemic process gap once the actual operation was observed. Sometimes the most effective root-cause analysis starts simply by going to the process, observing, and asking the right questions.

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Francisco J. Tapia Guerrero
ftapia@qualitascertification.com
www.linkedin.com/in/franktapiaguerrero
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Sayın;Frank Higley-Sanchez

Bazı durumlarda görüş açımızı geniş tutarak , yüksek bir yerden vb. Şekillerde olayları inceleme,detaylara inmek hangi çalışma ortamı olur ise fark etmez ekip olarak ta düşüne biliriz. Çünkü sen fark etmezsen bir başkası da görebilir. Bazen insanlar sadece iş yürüsün,üretim devam etsin vb. hiç bir zaman bitmiyor kimse "acaba" olur ve ya olmazı takmıyor kafasına yazınız da değilmişsiniz Kalite birimin den ya da iş güvenliği biriminden haberleri varımdır. İyi çalışmalar kolaylıklar dilerim. 

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LEVENT SERHAT DEDEOGLU
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Frank, this is a very practical example, and one point in your story particularly caught my attention: finding the incorrect capping setting explained the defect, but it may not fully explain why the system allowed that condition to reach the customer.

In my experience, this is where root cause analysis becomes more valuable. Once the technical cause is identified, I like to ask a second set of questions: What control should have detected this earlier? Why did it not? Was the setting independently verified after changeover? Were different bottle configurations adequately considered in the control plan? And why was the initial complaint classified as an isolated issue before these possibilities were examined?

Dilawar's point about the phrase "isolated issue" is particularly important here. Sometimes that conclusion is reached because recurrence has not yet been demonstrated, rather than because recurrence has actually been ruled out.

For me, an effective RCA should therefore go beyond "What caused the defect?" to "What weakness in the system allowed the cause to remain undetected?"

That distinction is often what separates a correction from a corrective action that genuinely reduces the risk of recurrence.

Thank you, Frank, for sharing a case that brings this distinction into a very practical context.

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Ahmed Rashidy Abdo

Founder & Managing Director | Quality For All (QFA)
Quality Management Consultant | Management Systems Auditor | International Trainer

Building professional competency and organizational excellence across the Middle East & Africa.

https://qfaplus.com
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Ahmed, that second set of questions is the one sites skip most often, because once the capping setting is corrected the pressure to close the record is enormous. I usually ask to be shown the control that was meant to catch it and whether it was ever tested against the combinations Frank described, since a check that only works on the common case is not really a control. Your recurrence point is well put too: not yet seen and ruled out are very different claims, and the record should say which one it is.

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Dilawar Laghari
Auditor, Consultant and Trainer
Audit Workshop
https://auditworkshop.com/
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Original Message:
Sent: 09-16-2026 10:19 AM
From: Ahmed Rashidy Abdo
Subject: Root Cause Realities

Frank, this is a very practical example, and one point in your story particularly caught my attention: finding the incorrect capping setting explained the defect, but it may not fully explain why the system allowed that condition to reach the customer.

In my experience, this is where root cause analysis becomes more valuable. Once the technical cause is identified, I like to ask a second set of questions: What control should have detected this earlier? Why did it not? Was the setting independently verified after changeover? Were different bottle configurations adequately considered in the control plan? And why was the initial complaint classified as an isolated issue before these possibilities were examined?

Dilawar's point about the phrase "isolated issue" is particularly important here. Sometimes that conclusion is reached because recurrence has not yet been demonstrated, rather than because recurrence has actually been ruled out.

For me, an effective RCA should therefore go beyond "What caused the defect?" to "What weakness in the system allowed the cause to remain undetected?"

That distinction is often what separates a correction from a corrective action that genuinely reduces the risk of recurrence.

Thank you, Frank, for sharing a case that brings this distinction into a very practical context.

------------------------------
Ahmed Rashidy Abdo

Founder & Managing Director | Quality For All (QFA)
Quality Management Consultant | Management Systems Auditor | International Trainer

Building professional competency and organizational excellence across the Middle East & Africa.

https://qfaplus.com
------------------------------

Dilawar, I completely agree. The pressure to close the record once the immediate technical cause has been corrected is exactly where a valuable RCA can become only a correction exercise.

Your point about testing the intended control against the actual conditions is especially important. A control should not be considered effective simply because it works under normal or common conditions; it needs to be capable of detecting the conditions it was designed to control.

I also like your distinction between "not seen" and "ruled out." That is a small difference in wording, but a significant difference in the strength of the conclusion.

This is where the audit trail becomes much more interesting: defect → technical cause → expected control → control failure → systemic cause → effectiveness of corrective action.

Thank you, Dilawar. That adds an important layer to the discussion.

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Ahmed Rashidy Abdo

Founder & Managing Director | Quality For All (QFA)
Quality Management Consultant | Management Systems Auditor | International Trainer

Building professional competency and organizational excellence across the Middle East & Africa.

https://qfaplus.com
------------------------------

Original Message:
Sent: 09-16-2026 11:38 PM
From: Dilawar Laghari
Subject: Root Cause Realities

Ahmed, that second set of questions is the one sites skip most often, because once the capping setting is corrected the pressure to close the record is enormous. I usually ask to be shown the control that was meant to catch it and whether it was ever tested against the combinations Frank described, since a check that only works on the common case is not really a control. Your recurrence point is well put too: not yet seen and ruled out are very different claims, and the record should say which one it is.

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Dilawar Laghari
Auditor, Consultant and Trainer
Audit Workshop
https://auditworkshop.com/
------------------------------


Original Message:
Sent: 09-16-2026 10:19 AM
From: Ahmed Rashidy Abdo
Subject: Root Cause Realities

Frank, this is a very practical example, and one point in your story particularly caught my attention: finding the incorrect capping setting explained the defect, but it may not fully explain why the system allowed that condition to reach the customer.

In my experience, this is where root cause analysis becomes more valuable. Once the technical cause is identified, I like to ask a second set of questions: What control should have detected this earlier? Why did it not? Was the setting independently verified after changeover? Were different bottle configurations adequately considered in the control plan? And why was the initial complaint classified as an isolated issue before these possibilities were examined?

Dilawar's point about the phrase "isolated issue" is particularly important here. Sometimes that conclusion is reached because recurrence has not yet been demonstrated, rather than because recurrence has actually been ruled out.

For me, an effective RCA should therefore go beyond "What caused the defect?" to "What weakness in the system allowed the cause to remain undetected?"

That distinction is often what separates a correction from a corrective action that genuinely reduces the risk of recurrence.

Thank you, Frank, for sharing a case that brings this distinction into a very practical context.

------------------------------
Ahmed Rashidy Abdo

Founder & Managing Director | Quality For All (QFA)
Quality Management Consultant | Management Systems Auditor | International Trainer

Building professional competency and organizational excellence across the Middle East & Africa.

https://qfaplus.com
------------------------------

I am not form Quality side but appreciate and enjoyed going through the entire thread starting with real life practical answer to Why? At our side we usually try to answer 3-5 Whys in a sequence for any problem as part of doing RCA

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Chand B. Shaik
IT Audit Expert, GOSI
Riyadh, Saudi Arabia
https://linkedin.com/in/cshaik
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