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

CCaantley said:

I'm curious as to where everyone who believes the system is 100% at fault thinks the system is to blame in this case?

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How can we know? In this case, how different/similar were the part numbers and the actual parts?
Example: If were talking about two different washers, PN 767Y7-8 and PN 767Y7-3, one has an internal diameter of 0.5" and the other has an internal diameter of 0.75", it is very easy to mis-ship the wrong one.

AndyN said:

Good question! Personal experience is just that, personal. The shipping clerk isn't you. Also, I'd ask if (objectively) the situation in shipping is IDENTICAL to when you worked there? Maybe it's busier. Maybe something (unique) was going on to distract the clerk. Who knows? To imply that instructions alone and following them is going to result in things the way you did them is incorrect, IMHO. It's like saying that you've never had a car accident, all drivers have to go through drivers' ed and therefore, there should be zero accidents...

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Truth be told, the shipping instructions are even more comprehensive then when I ran shipping. When I took on the Quality Manager position, the first thing I did was go through the shipping manuals and remove obsolete parts, took new pictures and added material info. I appreciate and understand your reply

Sidney Vianna said:

How can we know? In this case, how different/similar were the part numbers and the actual parts?
Example: If were talking about two different washers, PN 767Y7-8 and PN 767Y7-3, one has an internal diameter of 0.5" and the other has an internal diameter of 0.75", it is very easy to mis-ship the wrong one.

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One part was a solid cylinder with smaller cylinders at each end. The other was a hollow, threaded cylinder with a smaller hollow cylinder at one end. The first part number was XXX-004 the second XXX-464. All told, they are quite different.

CCaantley said:

Truth be told, the shipping instructions are even more comprehensive then when I ran shipping

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Did you create them?

In my career, I've seen the same thing. Instructions, written by degreed engineers, and given to highschool graduates (no degrees) to build complex assemblies. Needless to say, a) the operators didn't know what was written in the WIs (who uses that expression in real life?) and b) who'd use them if they didn't help create them?

...and at the end of the day...shipping instructions are just instructions, like the instructions on the side of the road on the maximum speed that no one really looks at.

There are countless ways to make it much harder to ship the wrong part, from simple barcoding to form fit 'nests' in the packing box that another part wont fit into, to (notably an extreme) granting access only to the correct part with no ability to grab something else.

When I worked in a shop making precious metal inks, it took three people to access the ink (the person responsible for the ink, the person responsible for the room in which the ink was, and a supervisory signoff to release the metal...in addition to the shipper.

Instructions may or may not get read...but no one is going to accidentally take something from a locked room when they have no key.
Simple barcodes can create a scream when things don't match (order & product).
Fitted nests can make you pause and ask "Why don't these fit in here right?"

Do humans make mistakes? Constantly. Looking at the system can generate ways to catch or prohibit the mistakes from going out the door...that's why you look at the system instead of the person. One can be "fixed"...the other can't.

Assigning blame to a person doesn't typically help the company. Looking for a solution in the system to prevent recurrence (or occurrence) CAN help the company.

AndyN said:

Did you create them?

In my career, I've seen the same thing. Instructions, written by degreed engineers, and given to highschool graduates (no degrees) to build complex assemblies. Needless to say, a) the operators didn't know what was written in the WIs (who uses that expression in real life?) and b) who'd use them if they didn't help create them?

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I slightly changed the shipping instructions that were already in use like getting rid of die information and deleting extraneous lines and boxes. I didn't actually create them, though.

Ninja said:

Assigning blame to a person doesn't typically help the company. Looking for a solution in the system to prevent recurrence (or occurrence) CAN help the company.

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I agree. I just was curious what people thought could be the system failure in my case. I'm always on the lookout to improve what I can.

FWIW, hoping it helps...

We did not have specific instructions for shipping beyond a vague overview of legal requirements.
We found it far more effective to put packing and shipping instructions on the packing list itself (that's what the shipper had as a pick list).
If we had had a "shipping manual" it would have been hundreds of pages long and no one would have ever read it.

Beyond that, a shipper packing out the wrong product isn't going to get fixed by any instructions...writing "ship the product number on the order" is a useless piece of text that anyone hired already knows before training. You may have to write it anyway, but it's a waste of ink from day one. Everyone knows that if a customer orders Product 464, you should ship Product 464, not 004.

...doesn't sound like you had a "system failure"...you had a person making a mistake...now how can the system be better?

echoing Andy's point: have you asked (in a nonjudgmental / no-harm way) what happened? have you investigated the facts? Have you observed the situation for yourself?

Bev D said:

echoing Andy's point: have you asked (in a nonjudgmental / no-harm way) what happened? have you investigated the facts? Have you observed the situation for yourself?

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The response we got when asking what happened was "I don't know, I f-ed up." It wasn't the first mistake the shipping clerk made, but it was the biggest. The higher ups decided to find a new shipping clerk.

Most of us initially choose not to expand the scope of our systems to include the homelife of employees or their commute.

We have other priorities and risk-based thinking tells us that we focus our system on what is important.

But as our system matures and we gradually remove more and more of its root causes of nonconformity other causes await our attention.

So, this is not static. We have to consider the maturity of our system and our current priorities.

At some point our colleagues may know they have their system's immediate support and counselling for a death in the family.

At some point we may enjoy courses in defensive driving or the Smith System courtesy of the system of which we are a part.