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 interests, the 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 relation cause-effect.  

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. 


Links to other Case Studies:

In-the Machine inspectors reduced to Standalone. Introduction “Actions to hide the never commissioned synchronisation of Inspector, Labeller and Conveyor, also implying a permanent impossibility for the Bottler to fulfill the triadic quest for: minimum losses, minimum downtimes, maximum rejection of defects and safety” “...service technicians’ skills are part of the final added-value of the Electronic Inspector, because they are those one who shape the future years of the equipment. World’s most expensive and higher Quality Electronic Inspector, left in the hands of some of the worst technicians, always perform much worse than World’s cheaper and lower Quality Electronic Inspector, left in the hands of some of the average-skilled technicians of the World” In the following, we’ll introduce the study of a pattern observed worldwide after 2004 in the operative reality of around one-hundred Electronic Inspectors sold to be operated in-the-Machine (Labeller, Filler, Capper, Closer or Seamer). Follow us in this Root Cause Analysis Case Study and you’ll discover what really is presently hidden under the surface of that beer. The Electronic Inspectors, whatever their Vendor, are built in two configurations: standalone, in-the-Machine. Standalone configuration Standalone configuration is by far the cheapest. 2-5 times cheaper than the in-the Machine. It does not include any connection, sensors, inspections, detectors nor logic relation with a precedent Labeller-, Filler-, Closer- or Seamer-Machine. Its: tasks are limited to handle a single Shifting-Register, rarely a couple of them; hardware is reduced to the minimum, typically one Trigger sensor over which the unique Shifting-Register is logically built, inspections and a rejector. fitting, wiring, starting and commissioning are accomplished in a limited time and, not being particularly complex tasks, they do not require the typically few available top-skilled service technicians. In systhesis: when configured to operate Standalone, all Inspectors imply an installation task that all of the Optoelectronics' service technicians fulfil. In-the-Machine configuration The Electronic Inspectors with locating positions and/or inspections in-the-Machine (Labeller-, Filler, Closer-, Seamer-Machine) are complex and their: tasks extended to handle several Shifting-Registers, typically two minimum; hardware is maximised, several Trigger sensors (inductive and optic) over which the various Shifting-Registers are logically built, many inspections and frequently more than one Rejector. their complexity is reflected in their pricing, always a factor 2-5 more expensive than the corresponding models operating standalone, years of practice, trainings, deep and true comprehension of the Shifting-Register's concept, are pre-requisite to an accomplished Commissioning. Commissioning honouring the Contract between an OEM or Vendor and a Food and Beverage Bottling and Packaging Company, also respectful of a row of legal requirements imposing, as an example, that the Machine Safeties cannot be left systematically disabled to the unaware Customers. Human-factor does matter Commissionings can only be named and underwritten that way in a worksheet whose siognature is asked you when: honouring the Contract between an OEM or Vendor and a Food and Beverage Bottling and Packaging Company, respectful of a row of legal requirements imposing, as an example, that the Machine Safeties cannot be left systematically disabled to the unaware Customers. We are suggesting the Readers that the service technician’s skills are part of the final added-value of the Electronic Inspector, because they are those one who shape the future years of the equipment. World’s most expensive and higher Quality Electronic Inspector, left in the hands of some of the worst technicians, always perform much worse than World’s cheaper and lower Quality Electronic Inspector, left in the hands of some of the average-skilled technicians of the World. Comparing Standalone & in-the-Machine installations’ pricings How to predict what should be the pricing of an Electronic Inspector’s installation, say its fitting, wiring, start-up, Commissioning and Operators’ Training ? Examing a posteriori many hundredths of different installations of Electronic Inspectors in Beverage Bottling Lines: where the above named installation activities had really been made, and made the only way the laws let them be valid in your country, because conformal to Safety rules and other technical good practices it is possible to see that a relation really exist, in different countries, part of Projects of Bottlers in competition (example, Coca-Cola vs. PepsiCo, AB InBev and SABMiller), whose Quality standards are different, configured with all of the existing spectrum of inspections, processing all existing kinds of containers (glass-, PET-, PRB-bottles, metal cans, crates and cases, etc.), from a wide range of productions, from 8 000 til 92 000 containers-per-hour, regression analysis shows an approximate but straightforward relation deriving be the comparison of the prices of the equipments, when the installation activities are not included. The installation pricing factor has empiric origin, nor we’d imagine what another way could be imagined to observe tendential relations which can only be obtained by linear regression studies a posteriori. As an example, if a Full Bottle Inspector costs 8000 € , ~10000 $ (weighs net 18 kg) is mainly but not only because that amount is proportioned to the sum of the values of its mechanical, pneumatical, optoelectronics, automation and documentation components. Another kind of Full Bottle Inspector of that same Vendor, priced ten times more, i.e., 80000 €, ~100000 $ (weighs 138 kg) shall need installation activities extended approximately to a duration 3.5 times longer than 8000 € model, needing just 3 days. Superior model costs ten times more than the basic: it sports many more functions and optionals to install (Rejectors, Triggers, cables, sensors), fit, wire, start, commission and finally train your staff. Five basic questions submitted to you own critical thinking: an Electronic Inspector needing 10 man*day of activities in your site, has been (strangely) delivered you after just 5 man*day ? What let you feel comfortable with the idea that its configuration is what you paid for ? What techniques you used to test it ? Maybe some test bottles had been passed one hundred times before to decide ? If this is the case, you have to know this is the kind of inspection a cheap Standalone Electronic Inspector does. An expensive in-the-Labeller Machine is paid to do many more additional useful things (like, advanced sampling or inspection in-the-Labeller) than just inspection at-the-Conveyor where the test bottles have been introduced. Would you order a new car, without to be informed before about its configuration, motor and performances ? We don’t think so, then it makes sense the following question: Have you received a precise listing of the functions assured you (Electronic Inspector’s Technical Guarantees) by the OEM or Vendor ? If not, why not ? Why Containers' Triggering is vital To let the Reader of these notes fully understand why all of the Triggering subject has so many pages developed to in this web site, there is to remark that: the identity of whatever object is its most fundamental information. It’d make no sense at all to speak of the “defective status of a container” in presence of ambiguity about “what container” is defective. In other words, containers’ Tracking, is much more important than whatever inspection, say whatever measurement of one of the physical properties of an object; when comparing Food and Beverage Packaging Industry with the Pharmaceutical Packaging Industry, we discover that the former with few exceptions discards as dangerous the rejection over an external Conveyor of the containers detected “defective” in-the-Machine. Following Pharma safety standards and customs, detection and rejection have to happen both in-the-Machine. The rejection has not to happen out of its Shifting-Register, one truly satisfying the requisites of rigidity and impossibility of the containers’ sliding out of the cells them attributed. Pharma Industry refrains to operate like Food and Beverage Packaging Industry operates following the OEMs and Vendors’ design choices; Machine-Conveyors-Inspector synchronisation Whatever the case, then also for relatively slow speed Labellers (<1.0 m/s), it is vital to synchronise the ramp-up and ramp-down phases of the Labeller and of the out feeding Conveyor, so that their speed difference results always <0.1 %. 0.1 % is a value knowingly close to the nonlinearity limit of the commercial Frequency Converters. Say the equipments regulating the speed of the motors in the Labeller and in the Conveyance systems. As an example, 0.1 % of divergence between bottle in-the-Labeller and same bottle at-the-Conveyor, at a speed of 1.5 m/s are 1.5 mm. 1.5 mm may appear a small divergence. But it is the maximum which can be allowed to be, keeping apart the today rare cases where containers’ speed is relatively slow (<0.8 m/s). Containers’ speed, being related to the containers’ kinetic energy following a quadratic law, enhances the slidings’ occurrences and then their negative effects. False Triggers and Data Sheets The Trigger controlling the Rejector, say the last one immediately before the Rejector, shall be exposed to count False Triggers, corresponding to bottles whose identity is unknown because lost. False Triggers which, in your own full interest, have to be absolutely be rejected by the Inspector, also if part of them corresponds to correctly labelled bottles. To let the Reader of these notes fully understand why all of the triggering subject has so many pages referred to in this web site, there is to remark that: the identity of whatever is the most fundamental information; it’d make no sense to speak of the defective status of a container in presence of ambiguity about “what container is defective”. the entire Pharmaceutical Industry discards and avoid as excessively dangerous the rejection of containers detected “defective” in-the-Machine, over an external Conveyor; detection and rejection have to happen in-the-Machine and not out of its Shifting-Register truly satisfying the requisites of rigidity and impossibility of movement of the containers out of the cells there attributed. In brief, Pharma Industry refrains to operate like Food and Beverage Packaging Industry is induced to operate by the choices of the OEMs and Vendors; How many of them has to be expected corresponding to correctly labelled bottles, then False Rejects ? A quite precise answer is given by the Inspector Counter menu for False Triggers, visible below as 0.01 %. Exactly that shall be the portion of the total False Rejects due to Falsely Triggered bottles. The mere existence of the Container Presence sensor shall force this rejection. Do not forget what seen above about the Transfer Point of the Labeller Machine's out feed starwheel.

IntroductionIn the following, we’ll introduce the study of a pattern observed worldwide in the period 2005-2014 in the operative reality of around one-hundred Electronic Inspectors sold to be operated in-the-Machine (Labeller, Filler, Capper, Closer or Seamer). …

Jammed Sampling table. Results of this over-sized Sampling Table were poor because of three independent Root Causes (italics) related to: Installation: the black colour side guide indicated by the arrow below, presents a profile inducing fallen cans due to cans’ anomalous fast deceleration. Fallen cans becomes jams in the end of the Table, where it starts the single way belt devoted to accumulate the orderly row of Filler Machine valves and Seamer heads; Design: the belts chosen are models with high friction coefficients, favouring fallen cans and successive jams; Design: no separate lubrification system existing with the effect that front of many more belts than necessary, no lubricant at all is visible, favouring fallen cans and jams. Incoherences like these are frequently encountered and the list above pin-points what to check first, when Sampling operations results in stopped Bottling or Canning Filler Machines. Results of this over-sized Sampling Table were poor because (Root Causes in italics) of: Installation: the black colour side guide indicated by the arrow below, presents a profile inducing fallen cans due to cans’ anomalous fast deceleration. Fallen cans becomes jams in the end of the Table, where it starts the single way belt devoted to accumulate the orderly row of Filler Machine valves and Seamer heads; Design: the belts chosen are models with high friction coefficients, favouring fallen cans and successive jams; Design: no separate lubrification system existing with the effect that front of many more belts than necessary, no lubricant at all is visible, favouring fallen cans and jams. Incoherences like these are frequently encountered and the list above pin-points what to check first, when Sampling operations results in stopped Bottling or Canning Filler Machines. Cans jammed, blocking the entire Table, after attempting a Filler-, Capper-, Closer- or Seamer-Sampling operation. Root Causes are the superimposed issues numbered above 2. and 3. Cans jammed, blocking the entire Table, after attempting a Filler-, Capper-, Closer- or Seamer-Sampling operation. Root Causes are the superimposed issues numbered above 2. and 3.

Case Study Sampling Table always jammedIntroductionTypical problems in a Food and Beverage Bottling Line derive by missing materials like motors, Frequency Converters, detectors, etc. In the following we’ll briefly study a Case where the “material” was much more than necessary. …

Case Study The Brewery which considered the TechnicalGuarantees part of a Contract to be honoured  ROC-curve of a Fill Level inspection. Imagine to pass 1000 times a test container through one and the same Electronic Inspector equipped with a dual Fill Level Inspection: X-ray and High Frequency (or, Optic with camera). …

IntroductionPowerade® is a famous energy beverage, the first in a row of energy drinks with great success launched in the World, after 1988. In July 2002, The Coca-Cola Company® updated the bottles of the standard Powerade to a new sport-grip bottle. …

Case study 27% rejects stopping all days a Beverage Bottling Line  The rejects' accumulation table of an Electronic Inspector in a Beverage Bottling Line, as it appeared to the eyes of the Operators and Management along 6 consecutive months after the day of the Line startup. …

reynolds numbers and fillin-2

Case study 1 year of Production lost   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 …

Milk and milk-based beverages, filled and capped in an aseptic environment, no preservatives. One more time, the cap is their Achilles’ heel, whatever the technology adopted during their filling. A slightly malpositioned cap is enough to clear all of the cares of the Aseptic Filling + Closing process, creating the optimal conditions for an organic contamination

Case study Cap presence control of sensitive beverages in 2001“X” is a great dairy filling and packaging plant. Here were installed, started and commissioned two standalone Full Bottle Inspectors in a new Aseptic Line for PET-bottled dairy products. …

milk aseptic filling med hr

Case study Cap Presence control of sensitive beverages in 2010Introduction “Y” is a great dairy filling and packaging plant. Here it has been installed a standalone Full Bottle Inspector in a new Aseptic filling Line for PET-bottled dairy products. …

99.5 % of the non-labelled bottles to the Market

Case study99.5% of the non-labelled bottles sent to the Market Non labelled and flagging-labelled bottles, manually rejected at the outfeed of a Labeller Machine. Manually rather than automatically rejected by the inspection system, because of a design-error in its configuration, amount of tracking Triggers photocells and Encoders. …

Canning Line's Layout relevance

Case StudyCanning Line’s Layout Relevance   IntroductionNo one of us has X-Ray's radiographic eyes. Because of this obvious reason, the cans’ content cannot be visually verified if, due to any reason, the Full Can Inspector is not active. …

Ampoules Filling and Sealing Machine. Pharmaceutical ampoules’ Filling and Sealing Machine. A container so intrinsically safe, does not need an identification of each one container along its filling, sealing and inspection phases. It can be safely inspected by a standalone Electronic Inspector, with sensors lying in the same Machine Cycle of the Filling-Sealing Machine. When Pharma Industry adopts containers different than ampoules, because having a Cap or Closure like the vials, the Electronic Inspection is always and only in-the-Machine. In-the-Machine at its highest level of safety, with the containers inspected and rejected into the Machine Cycle. Into the Machine Cycle and not over a separate Conveyor Cycle following the Machine Cycle, like in the case of the Food and Beverage Aseptic Packaging (image credit SCHOTT®, 2014)

Case study Electronic inspection of Pharmaceuticalsin-the-Machine-Cycle When speaking of guarantees of asepticity, Pharmaceutical Industry is since many decades what really and only retains the maximum know-how. …

punctured pharmaceutical co med

IntroductionThe Pharmaceutical field is the origin of the technologies adopted today in the Aseptic filling, closing and inspection of beverages without any added preservatives. Are the Food and Beverage Packaging standards competing with the Pharma standards of, as an example 10 years ago ? …

hardware faults 2800x1582@1x

Case HistoryGold-made electronic cardsImagine two huge cases arrived to your store today, filled with the spare parts you ordered and waited for 4-6 months. Electronic cards and other parts urgently needed to let your Machinery produce in Quality and Safety. …

topology of the saff-sequen 4096x2460@1x

The “Device”Fusing, considered the Root Cause of whatever explosion, is just one superimposed component of an extremely longer sequence of conditions before and after, greater and smaller, than the Fuzing. …

human-factor design and nuc-2 4096x2315@1x

What Root Cause Analysis’ names human-factor plays a decisive role. A role made decisive as root cause of the majority (over 50 %) of all of the incidents registered in the productive processes. …

A seismic Incident

False trail to the Root CauseWe’ll brief in the following the incident happened in 2011 in the nuclear power plant at Fukushima Daiichi, Japan, operated by the Tokyo Electric Power Company (TEPCO). …









This website has no affiliation with, endorsement, sponsorship, or support of Heuft Systemtechnik GmbH, MingJia Packaging Inspection Tech Co., Pressco Technology Inc., miho Inspektionsysteme GmbH, Krones AG, KHS GmbH, Bbull Technology, Industrial Dynamics Co., FT System srl, Cognex Co., ICS Inex Inspection Systems, Mettler-Toledo Inc., Logics & Controls srl, Symplex Vision Systems GmbH, Teledyne Dalsa Inc., Microscan Systems Inc., Andor Technology plc, Newton Research Labs Inc., Basler AG, Datalogic SpA, Sidel AG, Matrox Electronics Systems Ltd.  


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