An Evaluation of the Dilemma at Benevento Foods: Understanding Cause and Effect and Recommendations for Improvement

Full Answer Section

Understanding Cause and Effect

The incident of rubber contamination is a critical symptom of deeper, systemic issues within our production processes. To move beyond merely fixing the immediate problem, we must understand the chain of cause and effect that led to this dilemma. I will explain these concepts using diagrams, which are powerful tools for visualizing complex relationships, even for those new to systems thinking.

Effect-Cause-Effect Logic Tree Diagram (using the 5-Why Tool)

The 5-Why method is a simple yet powerful iterative questioning technique used to explore the cause-and-effect relationships underlying a particular problem. By repeatedly asking "Why?", we can drill down to the root cause(s) of an issue.

(Diagram to be inserted here - Hand-drawn or using software like Visio/Dia. It should follow this structure):

                  [Effect]
           RUBBER FOUND IN BAKING MIX
                       |
                       V
        ----------------------------------
        |              Why?              |
        ----------------------------------
                       |
                       V
        RUBBER COMPONENT BROKE OFF MACHINERY
                       |
                       V
        ----------------------------------
        |              Why?              |
        ----------------------------------
                       |
                       V
        RUBBER COMPONENT WAS WORN, BRITTLE, OR DAMAGED
                       |
                       V
        ----------------------------------
        |              Why?              |
        ----------------------------------
                       |
                       V
        COMPONENT NOT REGULARLY INSPECTED OR PROACTIVELY REPLACED
                       |
                       V
        ----------------------------------
        |              Why?              |
        ----------------------------------
                       |
                       V
        INADEQUATE PREVENTIVE MAINTENANCE SCHEDULE FOR WEARABLE PARTS
                       |
           --------------------------------------------------------------------------------------
           |                                                                                    |
           V                                                                                    V
    ------------------------------                                 -----------------------------------
    |          Why?              |                                 |               Why?                |
    ------------------------------                                 -----------------------------------
           |                                                                                    |
           V                                                                                    V
    **ROOT CAUSE 1:** **ROOT CAUSE 2:**
    **Short-term operational pressure** **Lack of comprehensive training for**
    **prioritizes production over PM.** **maintenance/operators on subtle wear.**
                                                                        |
                                                                        V
                                                            ----------------------------------
                                                            |              Why?              |
                                                            ----------------------------------
                                                                        |
                                                                        V
                                                            **ROOT CAUSE 3:**
                                                            **Absence of a robust "foreign material"**
                                                            **control program and checkpoints.**

Explanation of the Effect-Cause-Effect Flow

Mr. Benevento, let's walk through this step-by-step. The effect we observed is "Rubber found in baking mix." This is the problem at the surface, what the customer experienced.

1. Why was rubber found in the mix? Because a rubber component broke off our production machinery and fell into the mix. This suggests the contaminant originated internally.
2. Why did the rubber component break off? Because the component itself was worn, brittle, or otherwise damaged. Rubber, like any material, degrades over time with use.
3. Why was this worn or damaged component still in use? Because it was not regularly inspected for wear and tear, or not replaced proactively before it failed. This indicates a gap in our current upkeep practices.
4. Why were these components not regularly inspected or replaced proactively? Because our preventive maintenance (PM) schedule for such small, wear-prone parts was inadequate, or it was not strictly followed. We might be waiting for things to break before fixing them, rather than preventing the break in the first place.

This leads us to the fundamental reasons, the root causes:

• Root Cause 1: Short-term operational pressure prioritizes production over preventive maintenance. It appears that the drive to meet production targets or keep machines running might be unconsciously (or consciously) leading to a reactive approach to maintenance. If we're always pushing for output, comprehensive, time-consuming preventive checks might be deferred or rushed, leading to components wearing out unexpectedly.
• Root Cause 2: Lack of comprehensive training for maintenance and operators on identifying subtle wear in non-metal components. While our team might be good at spotting obvious breakdowns, they may not have been specifically trained on how to identify the early signs of degradation in rubber seals, gaskets, or belts that could lead to contamination.
• Root Cause 3: Absence of a robust "foreign material" control program and checkpoints. Even if a component degrades, there should be subsequent safety nets. Our current quality checks may not adequately include specific, rigorous visual or detection checkpoints designed to catch non-metallic foreign materials like rubber before packaging.

These root causes highlight that the problem is not a simple isolated incident but a result of intersecting deficiencies in our operational priorities, training, and quality control systems.

Causal Loop Diagram (CLD)

A causal loop diagram helps us understand how different elements in a system influence each other over time, forming reinforcing (vicious or virtuous) or balancing (self-correcting) cycles. It explains why a problem might persist or even worsen.

(Diagram to be inserted here - Hand-drawn or using software like Visio/Dia. It should represent the following loops):

Sample Answer

To: Mr. Marco Benevento, Owner, Benevento FoodsFrom: [Your Name/Title], IT Project ManagerDate: May 30, 2025Subject: Evaluation of Quality Dilemma: Root Cause Analysis and Recommendations for Improvement

Dear Mr. Benevento,

Following our recent discussion regarding the customer complaint about rubber in your baking mix and the impending BRC Food Safety audit, I have undertaken a comprehensive analysis of the quality issue using systems thinking tools, specifically root cause analysis. This report outlines the methodologies used, the findings from our investigation into the underlying causes and complexities, and provides both immediate and long-term recommendations to not only resolve the current crisis but also to implement sustainable quality improvements at Benevento Foods