Case study 


1 Year of Production lost


“18 months after the startup and two different analysis made by elements acting in conditions of conflict of intereststhe entire Packaging Line had an average daily efficiency lower than 38 %”



 The Reynolds’ Numbers appearing in all textbooks of Fluid Dynamics yet 18 months before we opened the book whose page is here reproduced, sentenced a design was ill-fated. Density does matter and the Industrial applications cannot abide by Physical Laws.  As we cleared elsewhere in these page devoted to what Graphene® may offer you, Root Cause Analysis is an investigational discipline part of the Scientific Methods. One born before the Industrial Revolution started at Manchester, United Kingdom. Physical Laws impose strict limits on what is possible and what is not. They depict the boundaries. Boundaries having topologic definition, structured by the Information Flows.  






“Root Cause Analysis most frequently is not defying technical issues, rather the erroneous ideas kept there along months or years, simply to protect the personal private interests of an individual”







“this Case History demonstrated what Humanity, wherever in the World, was yet knowing thousands of years ago: 

the primacy of the Ethic and Moral factors over all other aspects”



In the following a case where the Machine blamed by the Bottler never functioned correctly since the first day.   18 months later, and after two different analysis made by elements acting in conditions of conflict of interests, the entire Packaging Line had an average daily efficiency lower than 38 %. 


33 Simultaneous Root Causes

A telenovela staged 18 months before, we terminated in 72 hours, discovering a reality completely different than the one officially circulating.  After root cause analysis, discovered: 

….there were simultaneously 33 different, superimposed and independent internal Root Causes for the failures and malfunctions observed by whoever.  

Something which left astonished all of the parts, not only the Packager. These explained in a straight way why nearly each one shift of Production since 18 months looked chaotic.  The 33 Root Causes were superposing losses of production time and of quality. Each one component unrelated to the others. Others, related to environmental conditions, like the ambient temperature.  Easy to imagine how irregular and random the superposition 33 terms may result in these conditions.  Chaos the image remained imprinted in the staff's memory.  One of the 33 causes was dominant over all of the others: identified in 72 hours was banally fixed in matter of minutes.  

And that Machine which until that moment matured the highest probability to be thrown out and replaced by the Packaging Factory,  jumped to its real efficiency slightly superior to 96 % ! ….in a matter of minutes, but after 18 months lost not focusing the exact cause-effect relation.  

Three of the root causes were external, say due to errors or inefficiencies arising by the Packager and not by the Vendor of the Machinery. Immediately after having been advised about these three, the Customer Packaging Manager put in place all of the due actions and fixed them in a matter of few days.   However, well before we were charged to start this RCA, the Packager understood on his own that the pseudo-technical diagnosis of the “experts” were attempts of the other side to delay ab-eterno the contractually due activities and design modifications. Activities and related expenses covered by the Guarantee. Design improvements whose accomplishement was vital to let the Machinery have at least the contractual production efficiency (> 90 %).   The Machine originating the mess we described is not an Electronic Inspector.


What this Case Study really shows us ?

The dominant Root Cause encountered along 3 days and fixed in minutes, after 18 months of time lost ?  …are we maybe novel Albert Einstein ?  We’d like to caresse this explanation but, it’s too comfortable to be Truth.  The most probable Root Cause for such an extended period of time passed before someone, finally, pointed the finger with force to the dominant technical Root Cause for that disaster, is surely another.   In other words: it was too easy to encounter the Cause, to imagine it was not yet evident 18 months before to at least one in the row of experts who observed and reported on a daily base its effects.    No Machinery, however expensive, nor the most advanced Quantum Computer today existing, can be compared to the real capabilities of a single human being equipped with nearly 100 billion neurons.  That means that the entire technological progress is helped, made easier and faster by mean of the machines, e.g., by mean of CAD/CAM design, but that the human-factor, fundamental 2 millions of years ago, is still fundamental today.  It is the most important factor determining a success or its opposite.   Then, back of a “big problem”, one which last along time and seems untouchable, there is frequently a human-being.

Along the 18 months before our arrival on-site, many on both sides inferred the Truth.  But, someone stamped something like a Taboo over such discussions.  And that’s why it was necessary to have an Independent Observer, an external Third Party, to have the courage to challenge who was hidden back of the stamped Taboo.  Root Cause Analysis most frequently is not defying technical issues, rather the erroneous ideas kept there along months or years, simply to protect the personal interests of an individual against those of his own Company and of its Customers. Returning this way to the starting point: the conflict of interests.   When accomplishing over 100 technological Root Cause Analysis during past decades, ~67 % of them conducted to human-factor as the most probable cause, and not to events unrelated by humans like the Machinery or Process where RCA is applied. Machinery is simply not intelligent enough to conceive a lie to hide a Truth.    This Case Study does not show, as at a first sight it could be imagined, the effects of some design incoherences. On the opposite, it is showing the effects of the conflict of interests, remarking the veridicity of the statement by John Pike quoted above.  To lie, also systematically along commercial relations, unfortunately is legal.  Worse, this is the legal wherever in the World and not only in the USA, where at least SEC exists.  A self-evident Root Cause for a mass of negative consequences felt also by Food and Beverage Packaging Companies.  The kilometric snagging-lists regarding issues in new (still not accepted) Food and Beverage Bottling Lines, are an evidence confirmed by Bottlers’ Technical Directors in charge for the new Projects. 

From a basic point of view, this Case History demonstrated what Humanity, wherever in the World, was yet knowing thousands of years ago: the primacy of the Ethic and Moral factors over all other aspects. 


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