When I have written corrective actions, I have written them as honestly and to the best of my ability to explain them. I now have been told that if I write a corrective action where "operator error" has occurred and the operator has been re-instructed, this is no longer acceptable.

Our management says this is just "rubber stamping" a corrective action.

Comments please. What do I do now? How do I defend this position when it is the truth?

dbulak,
The environment that you work in, Is there a union involved?
Operator error within a union environment is a grey area and, If this is the case for you then, I would re-word your NC report to include all possibilities such as task element and ergonomic re-assessmnts, including training issues and the possibility of more than one opperator performong the task (Between shift work assessment).
Wallace.:agree:

You could be in a tough spot.
We have had some other threads on the board dealing with the validity of operator error as root cause. I would suggest doing a search to see what the other threads have to say.

For myself, I am not a big fan of operator error as a root cause. However there may be times, especially on internal issues, where it is legitimate. Wallace brings up some good points about addressing other issues such as ergonomics etc., but sometimes it just comes down to poor performance. If management doesn't like to admit that operators can make mistakes, ask them if they prefer operator stupidity any better for a reason. Or how about expressing it in terms of Process capability. "The process failed do to a deterioration in capability. Source of deterioration has been traced to the main control unit (in this case human) which will need to be repaired, or replaced."

If your management is dead set against operator error in all cases, then they had better be prepared to spend some big bucks idiot proofing every operation in the place.

Well enough of my rambling vent...

Questions to ask.
How long has this person been on the job? (experience/training)
Has anything changed in the task? (training)
Has anything changed in the environment? (ergonomics)
Has anything changed in the materials used? (process inputs)

If the person has been doing this job long enough, and no changes have occurred on the process then you are left with operator error.


James

Dbulak,
Are you performing a 1st, 2nd or 3rd party audit when you report your finding regarding operator error?
JKRH made a good point regarding expressing the outputs of your findings as process capabilities.
The culture of an organization is a good indication of internal and external commitment to QMS issues and, your finding of operator error may be the truth yet, auditor ethics whether they be internal or external must IMO adhere to an accepted code of ethics, I have allways refrained from giving my opinion even if my opinion is true and accurate during an audit.
I would suggest that you use the task element approach developed by Allan J Sayle refering to Management audits, this entails assesing Person, Item, Equipment, Information and Service, you may wish to report the persons' Competence, Training, Identification, Motivation and Attributes, Understand that this approach is NOT within the scope of ISO9001 yet, I have come to realize that this approach is a very efficient and effective method of allowing management to see the big picture regarding the most important part of any process THE PERSON who performs the task.
Wallace.:agree:

Two thoughts:

1) If you believe in Dr. Juran’s 85/15 or Dr. Deming’s extension of that at 94/6 (I have seen videos where he goes as far as 98/2), then the cause for the problem is System related and not Individually related.

2) Even if it is traceable to an individual, then I ask if the process of nonconformance is stable and predictable (i.e. people make mistakes and sometimes do stupid things). If the cause is ‘common’ and not ‘special’, then I think that the CAR may have been issued erroneously.

Most CARs are for system generated problems and as such, require system adjustments to correct. Correcting people (and so noting this on a CAR) may lead to temporary success (hiding problems or unusually high short-term focus), but system fixes lead to real improvement. Using the 5-Why approach should lead folks to system causes or program oversights, thus making a dent into the problem when corrected.

Just some thoughts…

Kevin

Kevin,
You have said what I should be saying, Thanks for getting me back on track :o
Appreciation of the system is what we might want to concentrate on for the education of the workforce regarding what may be an evident operator errror. I'm interested in the route that we are taking here, JRKH mentions the use of process capability to bring to managements attention the performance capability of the operator, At my place of work we use ISPC (In station process control), This measures all of the task elements that I mentioned previously and, We can all see the stats, My problem with this method of control is that, If there is no formal system in place and no appreciation of the system (Education) then, there can be no phsycological approach to operator motivation (Measure of Morale). :frust:
I mentioned in a previous thread that organizational culture may be a good measure of the root cause of operator error. What's your take on this dbulak?
Wallace.:agree:

I appreciate the advise given here. Thankyou again as always. But another question on the same subject. Is it then ok to use operator error when filling out a customer corrective action. Management has vetoed this also.

dbulak,
You are definately passionate about the operator error finding and, I believe that's a good thing, providing that you are able to communicate the operator error with the appropriate evidence and, wording it in such a manner that doesn't express judgement upon the operator.
Tha fact that you may have witnessed operator error is important to your findings and, you may want to concentrate a CAR on the training and development of the operators, Ofcourse if you have witnessed operator error that may lead to a safety issue, Then I would indeed report it to management imediately. I take it that your findings are recorded and filed?
Wallace.

Make life a little easier for yourself. Get management involved in these decisions by scheduling a team problem solving process.

While I do believe this happens...if you have 'many' operator error occurances then you are truely not getting to the root of the problem.

5 Why's? Keep asking and asking and asking~! Maybe there needs to be an SOP with the specifics that are missed frequently. Or, there could be a problem with your training or evaluation processes. All get the drift?

Good Luck, Eileen

Sam,
It's all fine and dandy sam, having a team problem solving process in place but, dbulak's audit findings are being vetoed by management, I believe that it may be an organizational culture problem that's the root cause and, If the management vetoes QMS internal audit findings, Management may jusy be paying lip service to the standard, What do you think Sam?
Wallace.:agree:

I guess I need to clarify how the operation is run, especially when it comes to answering cutomer corrective actions.
First, the operator has stock brought to him. He makes the set up, makes and records his inspections and finally runs the product. Unless he has a specific problem where he calls management, he controls the entire process from beginning to end. He is and does the final inspection because the product goes directly to packaging. Due to the nature of the product it cannot be re-inspected before packaging and shipping. So when management says that Operator error is not an acceptable answer, I feel like saying, "ok, if the operator didn't do it, who did?"

WALLACE, sorry for being passionate about the situation, but I am looking to do the right thing. Thank you and everyone for your inputs.

Anytime there is a lack of personal performance, there can only be two causes. Either there was a lack of knowledge (DK – deficiency of knowledge), or a lack in execution (DE – deficiency of execution). If the operator did not know, they retraining may help solve the problem. If the operator knew, but did not perform, they you must find out why. “Operator error” may, in fact be a true cause. The operator made a mistake. The intent was to perform.

An example would be a pitcher throwing a wild pitch. Did the pitcher know how to throw? Did the pitcher throw a wild pitch on purpose? Was the pitcher instructed to throw a wild pitch? Did management place barriers that prevented the pitcher from throwing properly. Did the pitcher’s apparel cause the arm to move unnaturally? Did the pitch just “get away” from the pitcher? Each of these questions asks a different question. It is easy for us in the stands to boo, hiss and holler. It is easy for us to say it was “pitcher (read operator) error”.

Saying operator error will only work if you can prove to yourself that it was just an operator mistake. If you can’t, find out what really caused the failure.

My nickel’s worth

Originally posted by Sam

Make life a little easier for yourself. Get management involved in these decisions by scheduling a team problem solving process.I agree with this and E Wall's post (and a few others as well...).

To me the key is whether or not this is recurring. If it's a recurrence it's time for an investigation.

Dbulak,
Never appologize for having passion for this problem that you are having, I believe you will arrive at a place where you will present further evidence if you "walk the process" and gain more insight into the actual and potential errors that are taking place.
Good luck.
Wallace.:evidence:

Wallace,
IMO team problem solving that includes management is the only effective way to resolve problems that occur in the process.

"It's all fine and dandy sam, having a team problem solving process in place but, dbulak's audit findings are being vetoed by management,"

Yes, but if they are vetoed in the team then it could be asked that management provide input as to the cause.


"I believe that it may be an organizational culte problem that's the root cause"

Could be, but that just leads to finger pointing.





I believe that it may be an organizational culture problem that's the root cause and, If the management vetoes QMS internal audit findings, Management may jusy be paying lip service to the standard, What do you think Sam?

Originally posted by dbulak
I guess I need to clarify how the operation is run, especially when it comes to answering cutomer corrective actions.
First, the operator has stock brought to him. He makes the set up, makes and records his inspections and finally runs the product. Unless he has a specific problem where he calls management, he controls the entire process from beginning to end. He is and does the final inspection because the product goes directly to packaging. Due to the nature of the product it cannot be re-inspected before packaging and shipping. So when management says that Operator error is not an acceptable answer, I feel like saying, "ok, if the operator didn't do it, who did?"


Insufficient product verification. Insufficient resources to properly verify product. This is a one man show. No cross checking. I can understand not wanting to accuse this valuable, he can do it all employee, of Operator Error. It's also an inappropriate work environment that burdens this employee to the point of losing his effectiveness. Put it on Management. The standard is loaded with clauses you can cite without delving into Operator Error. Here's just two:
The organization shall-determine criteria and methods needed to ensure that both the operation and control of these processes are effective.
The organization shall-determine the required verification, validation, monitoring, inspection and test activities specific to the product and the criteria for product acceptance.

Throw it right back at them. It's not your problem.:ko: :smokin:

I agree with your view Sam yet, Management vetoing regarding Dbulak's brick wall may lead to more abuses of the QMS:frust:
Energy said it Throw it right back at them. It's not your problem.
It may be one of those situations that have to come out with the dirty linnen.
Wallace.

I worked for a company whose management refused to accept "Operator error. Re-trained." as cause and corrective action. They did so because this had been permitted to become an acceptable and easy response to CARs.

A new manager put a stop to this. Over-reaction? Perhaps. And in the beginning it was extremely frustrating to the point of creating shouting matches during our Corrective Action Board meetings.

But, in the long run, it drove us to more effective corrective action because the great majority of the "operator errors" turned out to be otherwise.

If you have access to it, you might also check out what Juran's handbook says about operator error. It might be helpful.

Good luck

BRoyal -
C'mon, don't leave us in suspense. :eek:
I've got Juran's handbook ( 5th edition with the flattering picture of the good Dr. on the cover) and I can't find specific reference to operator errors in the Index.
Could you tell us, even if it's from memory or paraphrased.
Enquiring minds want to know!

BTW - I agree with your post, I was just curious about the reference.

Deming quotes that 94% of errors are inherent in the system, which is the responsibility of management, and are not the fault of the operator.

I would say that if your operator made an error because he was a complete dim wit then your system has still failed.

Why did you hire him to do this job ?

Why is your training inadequate ?

etc, etc

Dave Strouse,
I was curious to and found a para titled "Concept of self-control" on page 17.4 of the fourth Ed. Seems close anyway.

Originally posted by M Greenaway
Deming quotes that 94% of errors are inherent in the system, which is the responsibility of management, and are not the fault of the operator.

I would say that if your operator made an error because he was a complete dim wit then your system has still failed.

Why did you hire him to do this job ?

Why is your training inadequate ?

etc, etc

Absolutely! Training, Competency-all that good stuff. But,
Deming's quote (which I have not read) leaves 6% that could apply to human error. My contention is that after all root cause analysis is completed and it points to operator error, that's what you call it. If you look at the other thread that really discusses this, there are those that absolutely refuse to accept that as a reason. We're not talking about using it for everything that goes wrong, just when it's justified. Remember the old saying"show me a person who doesn't make a mistake and I'll show you a person who doesn't do a damn thing":ko: :smokin:

Like you say, this quote doesnt mean that operator error cannot happen, just that it is the minority of causes.

This should only raise concern if the majority of problems are put down to operator error.

Sorry about the lack of reference re: Juran. Check "worker errors" in the index.

Ben

I remember my boss saying that I should not work on the operator error, instead on the how to improve the process wherein the operator works. Or if it involves, the machine, made some adjustment on the machine.

Raffy wrote:
I remember my boss saying that I should not work on the operator error, instead on the how to improve the process wherein the operator works. Or if it involves, the machine, made some adjustment on the machine.

The idea of mistake/error/idiot (for those of us who have been around a while) is nothing new. However, as energy eluded to, people do make mistakes. I often say I never make the same mistake twice, I’m too busy making new ones! (From an old Beatle Bailey cartoon). :bonk: I also say I have zero tolerance for incompetence…unless it is my own. If you can prevent the error, by all means do. But bear in mind that employees will always (either through intention, or accident) find new errors.