I fell in love with quality systems because of a mturing event
I fell in love with quality systems because of a manufacturing event. Some years ago, I witnessed a deviation where a bottle of cell growth media leaked during transfer into a biological safety cabinet. The operator contained it, escalated properly, and a deviation was initiated. The investigation moved quickly: "operator error" was assigned as the root cause, with the conclusion that the operator had not been gentle enough during handling of the container. This was despite an eyewitness stating that the operator followed the procedure diligently and handled the bottle with care. I remember him walking into the room, visibly upset, saying the event conclusion would affect his yearly performance and bonus. Months later, two more similar events happened on the same process, with different operators. That's when it hit me. The investigation had stopped at the person when it should have started with the process. No one had checked whether the container was appropriate f...