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Question

Make a fishbone diagram from the information in the interviews


Interview 1 -

Joe received an injury last week and the interviewer was trying to determine the potential cause.

Joe - I was moving a packed box from the assembly line and hurt my back.

Interviewer - Why did moving the box end up hurting your back?

Joe - As I was moving the box I lost my grip on the box and tried to catch it as it was falling.

Interviewer - Why did you lose your grip on the box?

Joe - There was another box in my way and I tripped over the box because I didn't see it.

Interviewer - Why was there a box in the floor in your way?

Joe - I had accidentally left the box there before I went on break and just forgot to move it.

Interviewer - Gotcha. Thank you so much and I hope your back gets to feeling better soon.

Interview 2 - Jane is Joe's supervisor. The purpose is to determine what the current processes are in Joe's area.

Jane - Joe works on the assembly line and is responsible for sealing boxes, adding shipping labels, and then stacking the boxes on the appropriate shipping pallet.

Interviewer - Was Joe following the Standard Operating Procedures when the accident occurred?

Jane - No. He had left a box in the middle of his work area. The SOP says that the floor area must be clear of any foreign objects. 

Interviewer - Could the accident have been avoided?

Jane - Absolutely! This was definitely a failure to comply with the SOP.

Interviewer - Does Joe get hurt often?

Jane - No, this is the first time I can remember him getting hurt.

Interviewer - How many employees do the same job that Joe does?

Jane - We have 12 shipping stations, so that is 12 including Joe.

Interviewer - How many of those employees have missed at least one day of work due to a work related injury over the past month?

Jane - Only one other that I can recall. John slipped and fell a couple of weeks ago.

Interviewer - Can you tell me about the accident?

Jane - The way I recall it, he was walking back from the restroom to his workstation and slipped and fell as he came through the warehouse.

Interviewer - Thank you so much. I will let you know if we have more questions.


Interview 3 - Tom is the employee that slipped and fell on his way through the warehouse.

Tom - I was walking back across the warehouse from the restroom and slipped on fluid that was on the floor.

Interviewer - Were you walking in an approved pathway?

Tom - Yes. I was definitely walking between the yellow path lines.

Interviewer - Do you know what type of fluid it was?

Tom - I think it was hydraulic fluid.

Interviewer - Why was there hydraulic fluid in the pathway?

Tom - I have no idea. That is certainly not in my area of expertise. 

Interviewer - Thank you so much for answering all of my questions.

Interview 4 - Melanie is the Operations Manager in Warehouse A. She is the subject matter expert for all of the machinery in the warehouse.

Interviewer - Why do you think that hydraulic fluid could be located in a pedestrian pathway?

Melanie - The fork trucks and hand moved fork trucks are not supposed to be in the pedestrian walkways. However, there are two places in the warehouse where they have to cross the path to get to the other side of the warehouse.

Interviewer - Is it possible for the fork trucks to leak hydraulic fluid onto the pathways?

Melanie - Yes. However, we conduct maintenance on them regularly and check for leaks.

Interviewer - Is it possible for the enclosed system to leak hydraulic fluid?

Melanie - Absolutely!  Every hydraulic connection has the potential to leak.

Interviewer - What are the things that would cause them to leak?

Melanie - Usually it is either a function of the age of the fitting or the hydraulic pressure.

Interviewer - How do you track the age of the fittings?

Melanie - We don't. The plant is over 20 years old and most of the fittings have been replaced several times.

Interviewer - Do you track the hydraulic pressure on the enclosed system?

Melanie - Yes. We have three pressure gauges on the system. There is one at the discharge of each of the two hydraulic pumps and one located at the furthest point of the hydraulic line?

Interviewer - Does anyone track the pressure?

Melanie - Yes. The pressure is checked every four hours and recorded in a log book.

Interviewer - Thank you so much for the help. I will let you know if the team has any more questions.

Interview 5 - Following up on what programs have been implemented by the Safety Officer to reduce the number of accidents.

Interviewer - We are conducting a Six Sigma project to try to reduce the percentage of employees that are out of work due to injury. Please do not think that we are accusing you of the injury. In fact, we are trying to determine which processes the company could change to make the workplace safer. With that said, can I ask a few questions?

Safety Officer - Sure, we have tried a ton of things and I think that the goal may be just unrealistic in this type of workspace.

Interviewer - What type of training is conducted for safety?

Safety Officer - All employees receive initial safety training before they step foot into the warehouse for the first time. We also give them a copy of our Safety Handbook and have them sign that they have read it.

Interviewer - Any other safety training after that?

Safety Officer - There is annual training that we used to do in December, but that got replaced by other more intensive training when the CEO got involved last year.

Interviewer - What happened then?

Safety Officer - In June we implemented safety training before each shift, then in September we implemented training by department for those that had injuries.

Interviewer - Do you have the number of hours of safety training so that we could see if there were any significant changes based on those actions?

Safety Officer - Sure, we keep track of training hours by the day.

Interviewer - Have you ever considered incentives or punishments associated with injuries?

Safety Officer - That is where we started last year. On February 1st we tried an incentive program and ran it until March 15th. We didn't see much change so the Operations Manager changed it to a punishment for not wearing PPE program that ran from April 1st through April 30th.

Interviewer - You mentioned a Safety Handbook. Can you tell me about that?

Safety Officer - Sure, it covers what each individual is supposed to do to be safe. It has all of the PPE requirements by job description and says who is responsible. It also says that if you have an accident that you must undergo drug testing at that time to make sure that it was not alcohol or drug related.

Interviewer - Does it cover safety inspections?

Safety Officer - No, safety inspections are the responsibility of everyone.

Interviewer - Are the safety inspections written down somewhere?

Safety Officer - No, they are all informal.

Interviewer - Thank you so much for your time, you have been very helpful.

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