“I understand our biggest machine has been off-line for a day and a half?” I asked.

“Two days,” Camila replied. “It was down first thing yesterday morning, but we didn’t report it down until lunchtime.”

“And?”

“It’s fixed now,” she explained. “Someone made a mistake on the machine setup for a specific tool and over-torqued the main drive. The drive can handle the pressure, but the tool came apart and destroyed a bunch of stuff inside the cabinet, including the safety partition. No injuries.”

“And, the fix? What’s the corrective action?” I wanted to know.

“Yeah, we have to make sure the setting doesn’t exceed the tool tolerance,” Camila was quick to respond, hoping the conversation would be over, soon.

“The problem wasn’t a machine setting? The problem was that someone wasn’t paying attention, didn’t doublecheck, wasn’t thinking, wasn’t trained or didn’t have the capability. That’s what you have to fix first.”