Why do malfunctions keep recurring and how do you resolve this?

Almost every production manager is familiar with this pattern: something goes wrong, you perform a Root Cause Analysis (RCA), adjust the procedure, and add a checkpoint. A few weeks later, someone is back at your desk with the same problem. The checklist has grown longer, but the downtime has not decreased. How do you resolve this?

Properly checked, yet a malfunction occurred

Imagine: a young operator checks the temperature of one of your machines. It falls within the norm you previously determined. He checks it off and continues. An hour later, an entire batch is rejected.

The experienced colleague who is called in takes a look and says: “Yes, that temperature was within spec, but not under these conditions. You should have intervened sooner.” Thus, the young operator followed the procedure perfectly, yet things still went wrong. Because he did not understand the context.

More checkpoints do not help if context is missing

Many production managers have the same (understandable) reflex at such a moment: you add an extra checkpoint, further tighten the standard, or measure more frequently.

But if the underlying knowledge is missing, extra control only increases the administrative burden. The young operator will simply add an extra checkmark, but still does not understand what a certain value means in this situation, at this moment, with this line. The result: operators become uncertain and frustrated, and experienced colleagues are asked to help more and more often. They become overloaded… and so on.

The question that is rarely asked after an RCA: is the knowledge required to prevent this actually available? And is it available in a structured, user-friendly way that explains what is happening, why it matters, and what to do if it deviates? That knowledge is not available in most factories.

Why you cannot just write that knowledge down

Some organizations already take a good step and ask their best operator to write down their knowledge. But unfortunately, that is not enough. An experienced operator does not always know what they know. After years on the line, much happens automatically and by feel. Ask them to describe what they do, and you get a fraction of what is actually happening in their head. That combination of signals they unconsciously weigh, the exceptions they recognize, the situations in which they deviate from the standard: that does not surface through a form.

How you actually capture that knowledge

To bring that knowledge to the surface, you need the right questions. Targeted questions that make their decision-making logic visible. That is what we do at ELICIT.

Through an average of five interviews, based on a fixed methodology, we extract the experiential knowledge hidden in the mind of your best expert. We process that knowledge into a knowledge system that operators can consult at any time. In case of a deviation, in a new situation, in the middle of the night, in thirty languages. As if the experienced operator were with them 24/7.

The next malfunction starts here

If the same human errors keep recurring in your factory, or vary by shift, it is a signal that the overall knowledge level needs to increase. You do not solve that with an extra checklist and additional control. You solve it by asking the question: what do your best people know, and how do we transfer that knowledge to the rest of the team? Do you want to know how to do that? Schedule an introductory meeting and discover how ELICIT can make your expert knowledge accessible to everyone.