Root Cause Analysis:

EFFECT

ROOT CAUSE

MACHINESAggregate pushing of stocks on racks Fork blade exceeding pallet dimension (1.0 meter, shortest side) Reach truck fork blade designed for maximum pallet dimension of 1.2 meters

Protruding blade not clearly visible from operators location, resorting to unsafe putaway/ letdown practices

No official operators safety training conducted on the introduction of hazards caused by specific situations

Collapsed Stocks

Blade extension designed for reaching Depth 2 locations

Uneven blade movement sometimes occur when extension is activated

Hydraulic mechanism malfunction

No re-calibration done on the hydraulics of the identified MHE

Effect

Environment

ROOT CAUSE

Collapsed Stocks

Accidental pushing of pallet by fork blades

Wrong assumption resulting to inaccurate control of equipment

Visibility at higher racks hindered by awkward warehouse light tone color(yellowish)

Efficiency of current lux tone of light regularly reviewed

Effect25 cm vertical clearance from top of pallet (ice Cream Cones) rack ceiling No direct line of sight with the stocks on higher rack levels Stocks directly Stocks directly beneath target beneath target pallets obstructs pallets obstructs operators line ofof operators line sight in depth 2 2 sight in depth locations locations Confined mobility of operator limits his vantage points on target pallets from higher levels Visual confirmation of loose pallets in depth 2 locations being blocked by taller pallets Maximization of pallet configuration by Client (Uric) for space efficiency Operator is limited to his reach truck cockpit, allowing only horizontal movements on the floor Loose pallets being racked in Depth 2 Tedious Shifting of racked pallets into new locations Risks caused by increased pallet height were insufficiently/haph azardly considered

ROOT CAUSERacking safety for new pallet situation was not considered completely during agreement between Uric & Igloo Management last 2009 Geographical & working limitations of the operator

Man

Collapse Stocks

Maximization of pallet configuration by Client (Uric) by space efficiency

Fast movement of inbound stocks forces operator to save racking time

No clear safety work instruction was given to operators for the racking of new pallet configuration

Risks caused by increased pallet height were insufficient/haphaz ardly considered

Racking safety for new pallet situation was not considered completely during agreement between Uric & Igloo Management last 2009

IGLOO SUPPLY CHAIN PHILIPPINES, INCORPORATEDQUALITY ASSURANCE. ENVIRONMENT, HEALTH AND SAFETY DEPARTMENT Pareto Diagram of Causes Collapsed Stocks Resulting to LossCUMMULATIVE FREQ. 30.43

CAUSES 1no direct line of sight with the stocks on higher rack levels 2. pallet support bars incomplete/ loose or inadequate stretch wrapping 3no visual guide/ no documented process for racking activities 4. fork blade extension exceeding pallet dimensions/ uneven fork blade when extension is activated 5. tone of light being used (tungsten yellow) Total

OCCURENCES 7

PERCENTAGE 30.43

56.52 73.91

6 4

26.09 17.39

86.95 100

3 3 23

13.04 13.04 100

Legend: 12345no direct line of sight with the stocks on higher rack levels pallet support bars incomplete/ loose or inadequate stretch wrapping no visual guide/ no documented process for racking activities fork blade extension exceeding pallet dimensions/ uneven fork blade when extension is activated tone of light being used (tungsten yellow)

This Pareto Diagram allows the reader to easily distinguish which should be given priority more. In this case, rearrangement of design and style, shrinkage of prototype after wash, and bad specification of prototype before wash must get the attention of the management more because they get the 62.7% of the total causes and maybe if solved only minimum error will be encountered in the future.

5- Why AnalysisWhy #3 25 cm vertical clearance from top of pallet (ice cream cones) to rack ceiling Confined mobility of operator limits his vantage points on Target pallets from higher level Visual confirmation of loose pallets in Depth 2 locations being blocked by taller pallets Loose pallets being racked in Depth 2 Maximization of pallet configuration by client (Uric) for space efficiency ROOT CAUSE

Collapsed Stocks

Why # 1: No direct line of sight with the stocks on higher rack levels.

Why #5 Risks caused by increased pallet height were insufficiently/ haphazardly considered Tedious shifting of racked pallets into new locations Fast movement of inbound stocks forces operator to save racking time Risks caused by increased pallet height were insufficiently/ haphazardly considered

Geographical and working limitations of the operator No clear safety work instruction was given to operators for the racking of the new pallet configuration

Why # 2: Stocks directly beneath target pallet obstructs operators line of sight in Depth 2 locations.

Why #4 Maximizations of pallet configuration by client (Uric) for space efficiency Operator is limited to his reach truck cockpit allowing only horizontal movements on the floor