Is 'Operator Error' as Root Cause ever acceptable?

Umang Vidyarthi said:

"Unfortunately common sense is the least common of all the senses-Mark Twain".

A popular misconcept is to perceive 'Human Error' as an 'Operator Error'. At Toyota (refer TPS) , the operator error is a big no-no. In case of a failure, the manager personally approaches the site, and appologises to the operator for his failure of not providing a fool-proof system to avoid the failure. Further he sets-forth to error-proof the operation!

I agree with their line of thinking, that 'Operator-Error' can/should be eliminated by devicing suitable poke-a-yoke, so that the operator does not get an iota of a chance to commit the mistake.

Umang

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Without "flogging a dead horse" I think the point most professionals are making is not to use "operator error" as a "cop out CAUSE" where they have given up on any further Preventive Action in trying to reduce the Occurrence. Of course this may well be justified if the overall Risk (RPN) is deemed acceptable.

Richard Pike said:

Without "flogging a dead horse" I think the point most professionals are making is not to use "operator error" as a "cop out CAUSE" where they have given up on any further Preventive Action in trying to reduce the Occurrence. Of course this may well be justified if the overall Risk (RPN) is deemed acceptable.

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Be careful using RPN as an evaluation criterion. In certain industries (automotive), simply using RPN thresholds is discouraged.

Stijloor.

Stijloor said:

Be careful using RPN as an evaluation criterion. In certain industries (automotive), simply using RPN thresholds is discouraged.

Stijloor.

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Absolutely correct. RPN, either SOD or SO based, is only an indication to be used in conjunction with all other factors. In fact, when auditing and I observe this being used as the sole criteria for subsequent action (or non-action), I would probably have some comment. Never the less, if the SOD or SO is particularly low ( in comparison to others on that specific FMEA), rather than get into the semantics of, if "operator error" is a valid Cause, there are probably more important issues to concentrate on,

Umang Vidyarthi said:

"Unfortunately common sense is the least common of all the senses-Mark Twain".

A popular misconcept is to perceive 'Human Error' as an 'Operator Error'. At Toyota (refer TPS) , the operator error is a big no-no. In case of a failure, the manager personally approaches the site, and appologises to the operator for his failure of not providing a fool-proof system to avoid the failure. Further he sets-forth to error-proof the operation!

I agree with their line of thinking, that 'Operator-Error' can/should be eliminated by devicing suitable poke-a-yoke, so that the operator does not get an iota of a chance to commit the mistake.

Umang

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Hi Umang,

Wow, I never heard this thing about the Japanese, but I am very happy to know.
I tell you that every time I have a problem like "human error" or "operator error" I feel a little guilty, the first thing I do is go by the operator and inform him personally of what happened and informed him of the fact that I am sorry to write "operator error" in the corrective action because I know very well that the real fault is not his.

However, is my practice to keep a friendly relationship with all my colleagues (at least I try..), especially with the operators in the production (they are the ones who do the hardest work - even I was like them, until some time ago I was an operator and then either done a Quality Master and here I am and I've never forgotten where I started..), then every day before going in my office I make a step into production to greet people and ask how things are going, if all goes well, etc., they appreciate this and I see in their eyes something very beautiful - there is someone who is interested in them ..

Sorry, maybe I went a little out of the technical argument but that's what I felt to say and I say thanks for your intervention

Romanel

Romanel said:

Hi Umang,

Wow, I never heard this thing about the Japanese, but I am very happy to know.
I tell you that every time I have a problem like "human error" or "operator error" I feel a little guilty, the first thing I do is go by the operator and inform him personally of what happened and informed him of the fact that I am sorry to write "operator error" in the corrective action because I know very well that the real fault is not his.

However, is my practice to keep a friendly relationship with all my colleagues (at least I try..), especially with the operators in the production (they are the ones who do the hardest work - even I was like them, until some time ago I was an operator and then either done a Quality Master and here I am and I've never forgotten where I started..), then every day before going in my office I make a step into production to greet people and ask how things are going, if all goes well, etc., they appreciate this and I see in their eyes something very beautiful - there is someone who is interested in them ..

Sorry, maybe I went a little out of the technical argument but that's what I felt to say and I say thanks for your intervention

Romanel

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The system is meant to help the employees to do good work...

John Broomfield said:

The system is meant to help the employees to do good work...

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True. It is meant to help - but it can not insure and it has limited control, at best.

bobdoering said:

True. It is meant to help - but it can not insure and it has limited control, at best.

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I am suggesting that we do not stop mistake proofing the system's processes and its products. I see no limit to this. Humans as employees and customers need all the help they can get!

Romanel said:

Hi Umang,

Wow, I never heard this thing about the Japanese, but I am very happy to know.

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My eldest son and his wife are in Japan for more than a decade, so I learn a lot about japanese work culture, their ethics and virtues. My additional source of information are the books on their management and systems.(BTW in stead of ISO, they have their own QMS)

I tell you that every time I have a problem like "human error" or "operator error" I feel a little guilty, the first thing I do is go by the operator and inform him personally of what happened and informed him of the fact that I am sorry to write "operator error" in the corrective action because I know very well that the real fault is not his.

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It is really great that the 'feel' is from your heart. This is the major difference which seperates Japanese work culture from the rest. Whatever they do is with a 'feel' inside, nothing cosmetic. Many companies try to copy their methods but miserably fail, because they lack the 'feel' and devotion towads the system.

However, is my practice to keep a friendly relationship with all my colleagues (at least I try..), especially with the operators in the production (they are the ones who do the hardest work - even I was like them, until some time ago I was an operator and then either done a Quality Master and here I am and I've never forgotten where I started..), then every day before going in my office I make a step into production to greet people and ask how things are going, if all goes well, etc., they appreciate this and I see in their eyes something very beautiful - there is someone who is interested in them ..

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There is nothing wrong with the friendly gesture towards colleagues, as long as it does not turn you soft and effect your decision making. MBWA (Management by walking around) is considered a very good practice.

Sorry, maybe I went a little out of the technical argument but that's what I felt to say and I say thanks for your intervention

Romanel

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Do not have to feel sorry Romanel, it is perfectly allright to vent your feelings, this separates humans from robots. Besides, whatever you have said is very much a part of the technical argument.

Umang

John Broomfield said:

I am suggesting that we do not stop mistake proofing the system's processes and its products. I see no limit to this. Humans as employees and customers need all the help they can get!

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You are right John, the concept of error-proofing is catching up fast. Yesterday only I have checked the error-proofing installed on the last machine of a single cell line, where nine gadgets are installed with nine sensors & dial gauges. The operator puts the part through all the nine, and the machine will not start till nine green indicators are activated. It does not leave any room for mistake by the operator.

You have rightly said there is no limit, period. "Limit is restricted only in the mind, with imagination, opportunities are limitless"-Epicurus.

Umang

Umang Vidyarthi said:

You have rightly said there is no limit, period. "Limit is restricted only in the mind, with imagination, opportunities are limitless"-Epicurus.

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Epicurus notwithstanding, there are limits, mainly fiscal ones. A technology (or idea) may exist that will prevent all mistakes and defects in a given process, but be too expensive to invoke. We still have to make money. This isn't to say that we shouldn't be on the lookout and be open to new ideas, but facts is facts.