Informational Nonconformances and Defects - Operator Error, System Error, or both?

Being ISO/AS for 10 yrs now we went through alot and it has taken us 10 yrs to fine tune our system. We still go through this (Is it a system error or a personnel issue). We have (sorry, but dumby-proof) the system so much that when a 10 year operator just doesn't follow the work instructions it's a personnel issue and it goes in their employee file. There's gotta be a time when it isn't the system. When an employee has been trained over and over and they just seem to make the same mistakes again and again than you have to start banging your head against the wall. I just had one today where the material needed to run the job was clearly stated in the work instructions, the lead man and supervisor injected the dies using a different wax. Luckily the customer agreed to buy it. Now both of these individuals have been at their jobs for 13+ years. Sorry nothing wrong with the system here and their were no phone calls about deaths in those two people's life's. It was a Friday afternoon and all they thought about was the week-end.

Lexylou said:

Being ISO/AS for 10 yrs now we went through alot and it has taken us 10 yrs to fine tune our system. We still go through this (Is it a system error or a personnel issue). We have (sorry, but dumby-proof) the system so much that when a 10 year operator just doesn't follow the work instructions it's a personnel issue and it goes in their employee file. There's gotta be a time when it isn't the system. When an employee has been trained over and over and they just seem to make the same mistakes again and again than you have to start banging your head against the wall. I just had one today where the material needed to run the job was clearly stated in the work instructions, the lead man and supervisor injected the dies using a different wax. Luckily the customer agreed to buy it. Now both of these individuals have been at their jobs for 13+ years. Sorry nothing wrong with the system here and their were no phone calls about deaths in those two people's life's. It was a Friday afternoon and all they thought about was the week-end.

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These comments are in line with valid claims that it is, indeed possible to have operator error. Then the question becomes one of why the error was made - was it motivation, or was the error an honest whoopsie, and so on. Some people would suggest that if a 13 year operator was most interested in the fact that it was Friday, it could be arranged to make every day Friday with him/her. When it all comes down to the nitty gritty, people need to care about their work.

Well this poll has been around for a bit over 7 years now since I started it and I am glad to see it has gotten nearly 200 votes and it has initiated some spirited dialogue.

It looks like 85% of folks believe that employee error is a valid finding in at least some cases, but a clear majority believe that it would be valid 20% or less of the time. You Cove members are a wise bunch! Carry on!

Mike, thanks for giving us a summary of the poll you started years back. Interesting result isn't? The poll will now be closed.

we tend to blame operators if cant formulate an immediate solutions. this immediate thinking would lead to worst discernment...every problem carries along antidote, take time to assessment and pin-point loop holes to correct the process, for sure the reason why process is the changing needs, technology, requirements, and the like. we cannot direct pin point the operator to be the error. i would suggest evaluate more, that is a true blooded engineer, indeed operator pin pointers are doctors and not engineers for that matter.

Re: Here we go again...

Michael T said:

(Steps up onto the soapbox that was recently left by noboxwine)

Ahem.... (taps microphone)

Okay... we've been down this road before and I'll reiterate my stance.... People can be the cause of a non-conformance. It is foolish to rule them out. It is also foolish to say they are always at fault. Start with the system - if you eliminate the system as the root cause of the non-conformance - then you are only left with the operator (provided the raw material has been removed from the equation).

Take, for example, Joseph Worker. Good guy (or gal...we can say Josephine if you want... ) Jo has been on the job for 10 years and (contrary to Chickenlips' problem from another thread) always uses the work instructions to do the job. Lunch time roles around and Jo goes to lunch. During lunch he receives a phone call from his mother saying his favorite uncle has just passed away unexpectedly. Mom and Uncle Fred are on the left coast and Jo works on the right coast - so - funeral arrangements will be made in a few days - time enough for the family to get their tickets on Hotline.com and fly out.

Jo goes back to work - clearly not thinking about work - but rather thinking about Uncle Fred and his poor distraught mom on the left coast. Jo mispacks 20 of the next 100 cartons he is packing.

What's the root cause? (No - eliminating telephone calls at work isn't it... nice try... )

Food for thought for the weekend.

Cheers!!!!

Mike

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The possible root cause are:

1. There is nothing placed in the system to have 2nd person double check the products (in this case packaging) prior to shipment or QA inspection.

2. What is your procedure for rejects? Is any reject found during manufacturing process has to be reported non-conformance or you allow it to be recorded as just manufacturing rejects and be documented in lot history record?

3. If you have 2nd person double checking the final product prior to QA inspection or shipment and still have nonconformance. Then you have to change the list of qualifications you need prior to hiring an employee.


Overall... For me it's the system error.

Re: Here we go again...

super-adik said:

The possible root cause are:

1. There is nothing placed in the system to have 2nd person double check the products (in this case packaging) prior to shipment or QA inspection.

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This doesn't prevent the problem from occurring; there's nothing in the problem statement that indicates that there is no subsequent inspection.

super-adik said:

2. What is your procedure for rejects? Is any reject found during manufacturing process has to be reported non-conformance or you allow it to be recorded as just manufacturing rejects and be documented in lot history record?

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Irrelevant. The problem was that a distraught person made mistakes.

super-adik said:

3. If you have 2nd person double checking the final product prior to QA inspection or shipment and still have nonconformance. Then you have to change the list of qualifications you need prior to hiring an employee.

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How do you know without having seen the list? Isn't it possible for two people to make mistakes in series?

super-adik said:

Overall... For me it's the system error.

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But you haven't explained what might be changed in the system that would prevent the problem from happening.

I can think of one possibility, but it's a bit of a stretch. If the culture or atmosphere--or whatever you want to call it--in Joe's company were such that he could come back from lunch and tell someone about his distraction, and ask for help or to go home (without being penalized for it), it could probably help in those situations.

I am a late comer in this discussion; so what I gather is that there IS an operator error and we are attempting to analyze the root cause of it. These are some of my thoughts on the subject.

Main Causes of error apparently attributable to the operator, appear to be,

1) Distraction while at work - strong enough to affect his/her attention.
2) Lack of adequate job skill (knowledge, training etc.),
3) Level of Motivation & committment to the existing job (or degree of dissatisfaction with the current work/employment

For the present I shall deal with the 1st one.

1. Distraction: Here again there are a lot of variables, e.g. culture-specific, individual-specific and certain factors that are generally common to most normal individuals. These factors would contribute to the degree of sensitivity of a person to distracting situation that may (or may not) cause errors/mistakes on the job. This has to recognized - that there will be some operator errors in most situations.

My view is that you cannot altogether eliminate operator errors, though you can certainly reduce them by improving the other two factors mentioned above. And this brings us to the Management's table - they need to know & adopt appropriate measure that would enhance the motivation & commitment of the workers. It is not possible here to go into this subject in depth. But if we do accept that some operator errors may occur, we must know the damage-potential of an error at a given work-station and depending upon the criticality of the case we can have a 2nd inspection after the first one, without the second inspector knowing that that lot has already undergone one check. Not that the second operator cannot make a mistake, but that chance of both operators making the mistake is very much reduced

My two - cents, a factoid;

As I recall, long ago in a far away land, an industrious I.E. performed a test or series of tests involving inspectors or operators and how effective they were at catching defects.

As I recall the factoid - on their "best days", an inspector or operator would catch 80% of the defects in their work flow.

Regards,
Marty

I read an article that informed about an error occurring at a phase that the operator managed, and that phase is independent of operator's input e.g. Printer, machine, general equipment, computer, etc. anything else was said to be a mistake. This means that system errors are different from operator faults/mistakes.