CMS-2026-00125 / D4
Root Cause Analysis
Identify both occurrence and escape root causes.
Fishbone
Pareto
5 Why Active
5 Why Analysis
Why 1
Why 2
Why 3
Why 4
Why 5
Analysis Evidence
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Verified Root Cause
Occurrence Root Cause
Improper greasing during assembly due to missing poka-yoke and weak SOP adherence.
Escape Root Cause
Lack of process control and final verification for hinge lubrication.
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