● verified · ○ assumed · ◆ root cause · → handed to another team
↩ Maintenance
Double caps on Line 3 — about 40 units before we caught it at the checkweigher.
Thanks — when did you first notice, and how were the affected units contained?
Shift lead stopped the line at 14:22. Segregated to hold cage, QA notified.
What was the immediate fix on the floor?
Operator error — they weren't paying attention to the cap chute.
I'm not going to accept "operator error" as a root cause. What made that mistake easy to make? Would a brand-new starter on their first shift have done the same?
Probably — the guard wasn't fitted after the changeover. The capper was running with the chute exposed.
Good — that's a system cause we can verify. What evidence would show whether the guard was missing from changeover sign-off, and what are you doing in your direct control to stop a recurrence?
This is a read-only demo — the coach conversation is pre-recorded. Request access to run live investigations with your team.
Closure readiness
3 of 4 requirements met
✓Problem sharpened
✓Verified system root cause
✓At least one owned action (real owner + review date)
✗Every team-controlled cause has an owned action— 1 cause(s) still need an action with a real owner and review date.
·Changeover checklist has no mandatory guard-fit verification step