Case study 


Cap Presence control of sensitive 

beverages in 2010


Introduction

milk aseptic filling med hr

  Over 250 different food- and beverage-borne diseases have been described.  Most of these are infections, caused by a variety of bacteria, viruses or parasites

“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.  The equipment devoted to assure Safety to dairy products, say the most dangerous existing and thinkable beverages, being an Electronic Inspector visible in the figure below:

  • operating standalone, rather than in-the-Machine,
  • no automated Visual inspection by camera, of the Caps’ height,
  • no automated Visual inspection by camera, of the Caps’ inclination, 
  • no automated Visual inspection by camera, of the Tamper Evident Ring, 
  • no Leakage control by squeezing.  

To inspect bottles' sealing and leakage gives relatively poor results for an Inspector with two cameras, but no squeezing leakage control.   Imagine what is necessary to guarantee dairy products…


heuftr basic

  The real electronic inspector referred to in the present RCA Case Study.  Operating standalone, no one camera check of the plastic Caps closing the bottles.  Just Cap's Presence digital (on-off) inspection.  An equipment unadapt to the task to assure that bottles open because of malpositioned caps, do not systematically reach people.  Bottles filled with milk or other dairy derivates or juices, in Aseptic conditions, without added preservatives protecting humans.  These beverages cannot be inspected by an Electronic Inspector with the only “cap Presence” inspection, if the goal is to limit the ingestion of contaminated beverages.  Also, the fact that an Aseptic Bottling Line runs 23000 bph or less, does not add anticontaminant Preservatives to the sensitive beverages


Did they existed safer technologies in 2010 ?










Yes, they did.   The safe solution was in 2010 and is today:

  • in-the-machine approach, where the Electronic Inspector has its own electromagnetic inspection cooperating with tens of others whose measurements are independent, lying in the Capper and Filler machines.    An approach where each one container having lost its own originally attributed identity, has to be mandatorily rejected, also if the visual inspections of the Electronic Inspector saw it correctly capped;   
  • a thorough inspection for the Cap conditions (height, inclination, tamper evident ring) with at least two cameras.

An example of the in-the-machine configuration of an Electronic Inspector from which they can be expected much higher hit ratios also for small Caps’ defects, with two cameras and no squeezing, is depicted in the figure below.  The figure refers itself to a device we system-integrated at Nestle’ Yinlu® (at Jinan, China).


nestle yinlu 2800x2100@1x













“...malpositioned caps, open bottles with preservatives-free milk or juices are just the tip of the iceberg of Projects not fulfilling the Bottler’s Order in terms of Food and Beverage Safety.   

Then, Root Cause for contaminated persons is at least, willingful negligence”

 The Case Study hints to an Aseptic Beverage Bottling Line, compelled to produce sensitive dairy products with only a Cap “Presence” Inspection.   A safety level nearly opposite than what can be reached, as an example, by the installation depicted on right side.  Here, similar dairy bottled products are controlled by a couple of cameras, assuring a full 360º coverage of the cap and of the tamper evident ring. The electromagnetic-only measurement approach is not the optimal solution.  But, in the Case Study here presented, each individual Cap results independently controlled in the Capper by mean of mechanic systems sensible to the Torque.  All of the measurements correlated to a uniquely identified bottle (in-the-Machine operation mode).  Imaged one of the Bottling Lines of Nestle’-Yinlu at Jinan, China, installed and started by our Staff


It features a proprietary design of the interfacing toward the Aseptic Bloc Filler + Closer.  Interfacing three different Machines (Filler + Capper + Inspector) to let each one bottle be rejected on the base of the joint probability of several independent measurements of a random variable.   A theorem defines such probability much lower than that possible to an Inspector configured standalone at the Capper out feed.   Without such kind of technical solutions, also the best existing Aseptic Filling Bloc and the most cared process, terminates in contaminations, simply because of leaking bottles whose cap is not closed.    


Root Cause

If the safer technologies, whose original application should have prevented or however greatly limited the occurrence of contamination of final Customers exist, then it is possible to restrict to just two cases the Root Cause for such an event.   Place yourself in the position of the Plant, Quality Control and Production Managers, after news circulating in the Press and other media like the TV or Internet, showing final Customers hospitalised with what they appear symptoms of foodborne poisoning, after having drinked their beverages.   The Case Study outlined a Project ignoring that an Aseptic Bottling Line running 23000 bph or less, surely does not add anticontaminant Preservatives to the sensitive beverages.   The Aseptic filling remains without preservatives at 7200 bph as much as at 72000 bph.    An Aseptic Bottling Line is more expensive than one for common non-Aseptic nor Ultraclean-filled beverages, also because it has to assure additional Quality to the Product.    “It has to assure” meaning that malpositioned caps, say open bottles with preservatives-free milk or juices, are one of the ways to represent Projects not fulfilling the Bottler’s Order in terms of Food and Beverage Safety.    Then, front of cases of contaminated persons the Root Cause is at least, willingful negligence.    Quite clear, but ...willingful negligence of Whom ? 


sensitive food and beverage



“Oasis Brands, Inc. Recalls Products Lacteos Santa Martha Because of Possible Health Risk

Contact
Consumer:
305-599-0225

FOR IMMEDIATE RELEASE - October 16, 2014 - Oasis Brands, Inc. of Miami, FL is recalling select lots of various Lacteos Santa Martha products with Best by dates of 07/01/14 through 12/31/14, because the products has the potential to be contaminated with Listeria monocytogenes, an organism which can cause serious and sometimes fatal infections in young children, frail or elderly people, and others with weakened immune systems. Although healthy individuals may suffer only short-term symptoms such as high fever, severe headache, stiffness, nausea, abdominal pain and diarrhea, Listeria infection can cause miscarriages and stillbirths among pregnant women.

The recalled products were distributed in Florida, Georgia, Tennessee and North Carolina from April 1st thought October 14, 2014 to distributors and retail stores. The products can be identified by the batch ID code (best used by date) sticker on the label of the plastic bag of 07/01/14 through 12/31/14.  

FDA is investigating illnesses associated with the product.

The recall is the result of routine sampling by The Virginia Department of Agriculture and Consumer Services Food Inspectors and subsequent FDA environmental samples that revealed the presence of Listeria monocytogenes. The company ceased production and distribution of the product as FDA and the company continue their investigation as to what caused the problem.

Consumers who have purchased the Lacteos Santa Martha products are urged to return it to the place of purchase for a full refund. Consumers with questions may contact the company at (305) 599-0225 Monday thru Friday 9:00 am - 4:30 pm EST.

U.S. Food and Drug Administration

10903 New Hampshire Avenue

Silver Spring, MD 20993, USA

 1-888-INFO-FDA (1-888-463-6332)”

Willingful negligence of Whom ?

...of the OEM or Vendor of the Machinery or the inspection equipment, or of some of the Staff of the Bottler of Aseptic beverages in charge of that Project during its early Design phase ?    In the following we’ll examine two different scenarios:


1.   Of the Bottler ?

The juridical “divide” deciding the nature of the Root Cause and its attribution is the existence of an official written, undersigned (Contractual) communication of the OEM or Vendor on a date before the Order of the Bottler.   A technical communication explaining that Cap Presence inspection is not a technology compatible with Food and Beverage Safety.   If such a communication existed, then the Bottler preferred a cheap and risky technology.   He has freedom to choose a Food and Beverage Low Safety Policy, if he wants.   The eventual negative outcomes included.   No doubt if he preferred the cheapest and riskier technologies, the annual premium he’ll have to pay to an Insurance Company in exchange for the coverage (Product Liability Insurance) of the risk to produce in those Conditions, shall be higher than with expensive technologies yet worldwide recognised as Quality standards.


2.   Of the OEM and/or Vendor ?

But, what if the official written Contractual technical communication about the fact that that Equipment cannot assure the safety of dairy products, filled in an Aseptic ambient without preservatives added, never happened ?   Then the Root Cause has to be ascribed to the Machinery's OEM (or, inspection equipment’s Vendor).   Not to write openly about such well known risks to a prospected Customer, presenting him alternative, also if more expensive technologies, can let artificially gain an Order for an entire multi-million dollars Beverage Bottling Line.  “Artificially” because the Competitors’ Offers to that same Bottler for that same Project shall look “artificially” more expensive.   

Clearly, such economy corresponds to missing basic Food and Beverage Safeties, then being an intentional falsification, and not a good-faith mistake.

One allowing to enrich someone at the expense of others, leaving to the others consequences that, if they’d have been warned before to sign a Contract, they’d have never accepted.    In this case, nearly wherever in the World and following the negative outcomes of the intentional falsifications, Tribunals shall decide this is much more than Machinery's OEM or inspection equipment’s Vendor willingful negligence.   Any doubt ?   As an example, Google the keywords: 

                                                    “food scandals” 

                                                    “soft-drinks contamination” 

and you’ll be presented many results.  So many results that a human-life is not long enough to read.    In the meantime, they exist Procurement Dept. and Project Management Dept. staff, thinking their Company has no responsibility if “did not passed technical guarantees to the prospected or actual Customer”.    Thus forgetting that the fact they did not passed Guarantees (that in the reality they received by the Vendor) could be later interpreted as  proof of a scheme which can be resumed as ...to increase the profits at whatever price, also endangering Others’ health.   The fact that the Vendor passed them these Guarantees in a confidential way, does not impede today the retrieval of the data.    If this second scenario is the Root Cause, is something with effects just between Bottler and OEM/Vendor.   Bottler’s responsibility toward his final Customers remains always and however.   The fact that the Bottler has the capability to show his good faith was betrayed by statements or missing statements of the OEM/Vendor, does not reduce substantially his liability.    Why not ?      Because He has the duty toward his Customers to take all cares to prevent things like these from happening, and not the OEM or Vendor.    



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). …









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