After thinking about the "certified shipment" thread a bit I decided to try my first poll. I hope I don't screw it up! So here goes...

Some very learned folks here believe, in the event of a nonconformance or defects, that “the system is always to blame” and never the operator. Deming proposed the system was at fault about 96% of the time (someone correct me here if my percentage is wrong – I’m going by a very fallible memory), but that “operator error” did exist. What do YOU think? Feel free to expound on your vote by posting as well.

Operator Error does exist from time to time. We are mammals, not machines and special causes occur. But, in my experience I'll have to agree that nonconformances occur 95% of the time, due to a feeble system----especially repeats. In our business culture, however, it's much easier----- and we feel better by placing the blame on an individual, single them out as incapable and shift the attention away from ourselves-----the creators of the system-------rather than accept the need for change. It would admit that we are human and some of us can not accept that. Plus, it's much easier to complete an 8-D by saying "oversight"-------"operator retrained". Gimme a flippin' break. Signing off my soapbox----noboxwine.

:frust:

Just doesn't sound the same does it? If we find there is a system error, could that be traced back to a human one (management)? :confused:

Consider: An employee inserts a part incorrectly in a machine and nonconforming part is formed. Human error, right? Well, perhaps it is a system error for allowing the employee to insert the part incorrectly (error proof the operation). However, should someone not have considered this possibility during planning? Oh another human error. But what in the system allowed the potential insertion error to be overlooked? We could go on and on.

The bottom line is even system errors will eventually be traced to human errors.


How do I come up with this stuff? :bonk:

I'll stick with the old 80-20 rule. However when the mistake has been made percentages really don't count and it doesn't matter who/what made the mistake. What matters is lessons learned and actions implemented.
As long as there is an operator there will always be an operator error.

Sorry, but I can't vote on this one - the system and those within it are not seperate, but overlapping, and, to make it more interesting, fluid.

As with human/machine interfaces, human/system interaction is sometimes hard to delineate, especially when you consider the thought processes (training?) that come into play.

Add to this the fact that human beings can change their outlook from minute to minute, depending on their environment, some of which is hard to control. Is the fact that someone's spouse yelled at them before work part of the system?

This is an interesting thread, but I will be surprised if a definitive answer is found.

It doesn't matter what business you are in, it is a people business.

(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... :D ) 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... :ko: )

Food for thought for the weekend.

Cheers!!!!

Mike

MT,

Nice speech; good analogy. According to some, in your example of Joseph Worker, the system was at fault, period. The system is ALWAYS at fault. I have honestly tried to convince myself that this could be possible, but alas I was unable to buy into that philosophy and doubt that I ever can. I kinda went on a rant in the "certified shipment" thread explaining (in part) why I feel this way.

Craig -- I agree "the system" includes and is created by people, but in this case I'm using definitions such as Deming used, separating the "operator" (Joseph in MT's example) from the "system" which is created by higher-ups (people who get paid more!).

But isnt the reason we have systems because we employee humans, and they are prone to errors ?

An interesting question that just crossed my mind (having voted 96%) is - at what point do we stop blaming the system and start blaming the operator ?

Can we say we have a good system if it allows operators to error ?

In the analogy given, should we have a system prone to the whims of the emotional state of our employees ?

MG,

I'm suprized by your vote, but thanks for voting.

As for "should we have a system prone to the whims of the emotional state of our employees " -- how can you possibly do otherwise in all cases?

How could you truly error-proof Joseph's job in all industries/situations? Have someone double check him? No, 100% test won't do it as you mentioned as being only 80% accurate in another thread. In the realm of practicality, how do you do it?

What if Joe is a driver delivering the boxes and he has a wreck -- crashes the truck. How do you error-proof that, make it "not prone to the whims of the emotional state of employees" as you say? Figure that one out and the world will beat a path to your door and you will be VERY rich, famous, loved by millions, a Nobel Prize winner, and solely responsible for saving thousands of lives each year.

Mike,


I wonder what the poll results would be if this were given to non-quality types.

Regards,

Kevin

M Greenaway said:

But isnt the reason we have systems because we employee humans, and they are prone to errors ?

An interesting question that just crossed my mind (having voted 96%) is - at what point do we stop blaming the system and start blaming the operator ?

Can we say we have a good system if it allows operators to error ?

In the analogy given, should we have a system prone to the whims of the emotional state of our employees ?

Good questions... Considering the fact (?) that none of us has ever seen a fool proof system: Surely the system should be "robust" enough to withstand outbreaks of human falliability?

What I'm saying is: Mistakes will happen. Some of them will make the system reel, but the system should not be brought down by them.

We'll never be able to prevent everything. That amazing gadget between our ears will keep coming up with new ways to fail (However: Consider all the things we do *correctly* every day).

/Claes

All

Exactly !

We cannot build a fail safe system, it is a state of perfection that we will never reach.

But should we blame the operator and ignore trying to improve the system ?

At what point do we say 'our system is good enough - the operator should not have failed, it must be their fault' ?

Michael T said:

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

Ahem.... (taps microphone)

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... :ko: )

Food for thought for the weekend.

Cheers!!!!

Mike

Being a realist with compassion:

Root cause is that Joe/jo received bad news that caused him/her an inability to focus wholly on the job at hand. This was not the fault of systems, nor was it Joe's fault (assuming he did not murder his uncle). It was an isolated incident that is not going to happen at any predictable frequency.

We (the company) will continue to assist our employees in any way we can during periods of family crisis, reaffirm our commitment to provide another operator to assist an employee when something like this happens and allow them to leave their shift when necessary. No corrective or preventive measures will be put in place beyond letting the customer know what happened and making it right by them through replacement, rework or monetary concessions.

Case closed, we took up a collection to help Joe buy plane tickets, he walked out at the end of his shift with $550 and one of the supervisors helped him to get his tickets bought on-line. The customer understood, and shipped back the defective product, which we replaced the next day via UPS Red.

Not everything has to be a big, full-blown investigation, nor does every issue need to create panic to find corrective action. It took me about two minutes to assess the issue and make a decision based on our company policies. Now, I have to quit screwing around and get a plant sent to the funeral home for Joe's uncle. Hey, which funeral home did you say that was?

Have a good one!

Thoughtful reply, Steel. If I were the customer I'd be completely satisfied with your solution.

One thing to keep in mnd is that often something a little less dramatic than the death of a family member happens in the life of an employee that may cause him/her to perform at less than their normal level. He/she may tell no one, so it won't be obvious, you might just hear something like "I have no idea why I did that -- I just goofed". It happens, and no economical system I can imagine will "goof proof" every process every time, which most folks seem to believe based on the poll results thus far.

M Greenaway said:

All

Exactly !

We cannot build a fail safe system, it is a state of perfection that we will never reach.

But should we blame the operator and ignore trying to improve the system ?

At what point do we say 'our system is good enough - the operator should not have failed, it must be their fault' ?

Just borrowed this from a previous post:

Of course, you're right about using "human error" as the last result of the investigation. I've addressed this scenario before, but a nicer version is:

Data Entry error results in incorrect part is sent to the Customer. This is a slip of the finger on the keys. We call it "happy fingers"
1st Why? "I made a mistake"
2nd Why? I made an error. Don't you get it?"
3rd Why? "Look, haven't you ever made a mistake? What was YOUR reason? Go see my Supervisor."

Supervisor is asked the 5th "why?". "The guy made a mistake."
6th Why? "He made a mistake. What do you want, blood?"

There comes a time when you get frustrated with the amount of time that is spent to come up with a good CA/PA. The customer understands mistakes, gets the right part and orders something else. He/she doesn't have a problem with it. After all, some Customers (those who admit it) also have employees who make mistakes.
Most problems are explainable, but occasionally there is no clear answer so you become "creative" with cause/preventive action just so you can get on with life. I also feel if you have enough people to throw at a problem, it's easier. Most small companies do not have the resources. I'll stop here because it's my pet peeve and I become emotional when it comes to overbearing large customers who demand action on anything, regardless of significance.

I would only add that asking 5 or more "Why's" can result in being sprayed with a pesticide when you have been told from the beginning that it was a mistake. For those who would advocate "idiot proofing" the process, I say that it is not very compassionate to instruct HR to amend that hiring process to make sure that that they don't hire idiots! :vfunny: :ko: :smokin:

Sorry - where does compassion come into it ?

M Greenaway said:

Sorry - where does compassion come into it ?


Martin... please tell me you are kidding...

Tis getting close to Christmas and Santa is watching...

:eek:

Mike

M Greenaway said:

Sorry - where does compassion come into it ?


and you British are always making fun of us yanks for the inability to appreciate ironic or subtle humor.....:bonk:

guess you had to be there for the thread where Marc said he wanted to see what kind of avitar I would use before he died.

Have a good one!

Seriously guys - should we accept that our recruitment process gives us a bunch of idiots to work with purely on compassionate grounds ?

Even ISO9001 says something loose about competency requirements.

OK having recruited an idiot lets do all we can to improve him/her, but lets also improve our recruitment process - thats what its all about.

Dont recall a clause from the 94 standard, or a section from the 00 standard, or one of the eight principles, or Demings system of profound knowledge, or Jurans quality handbook, or the business excellence model, or six sigma, lean manufacturing, 5 s, Kaizen, etc etc etc ever mention compassion.

Even the best systems cannot prevent operator errors. But the system ought to be able to contain the consequences of those errors, and the system ought to be able to prevent repeated errors. Just my two cents...:smokin:

M Greenaway said:

Seriously guys - should we accept that our recruitment process gives us a bunch of idiots to work with purely on compassionate grounds ?

Even ISO9001 says something loose about competency requirements.

OK having recruited an idiot lets do all we can to improve him/her, but lets also improve our recruitment process - thats what its all about.

Dont recall a clause from the 94 standard, or a section from the 00 standard, or one of the eight principles, or Demings system of profound knowledge, or Jurans quality handbook, or the business excellence model, or six sigma, lean manufacturing, 5 s, Kaizen, etc etc etc ever mention compassion.

Martin,

Maybe I'm the idiot here. You seem confused about the "compassion" issue and I wasn't -- until your posts made me question myself. Here's my take: Since Steel mentioned "compassion" first, I assumed the "compassion" came in when her company helped the ficticious Joe with his work, took up a collection so he could visit his family and mourn the loss of a loved one, and helped him buy the plane tickets. Not a result of any required act by any ISO standard, Q guru, handbook, business excellence model, etc. but just a thoughtful, nice act of human decency, no more, no less.

If you suggest ole Joe was an incompetent "idiot" because of the mistake he made, and/or that HR failed in the hiring process...well, if you think that in this case I sugggest that you've either been in the "sauce" or else you simply don't get it. I'll let it go at that.
:bonk:

Mike S. said:

Martin,

Maybe I'm the idiot here. You seem confused about the "compassion" issue and I wasn't -- until your posts made me question myself. Here's my take: Since Steel mentioned "compassion" first, I assumed the "compassion" came in when her company helped the ficticious Joe with his work, took up a collection so he could visit his family and mourn the loss of a loved one, and helped him buy the plane tickets. Not a result of any required act by any ISO standard, Q guru, handbook, business excellence model, etc. but just a thoughtful, nice act of human decency, no more, no less.

If you suggest ole Joe was an incompetent "idiot" because of the mistake he made, and/or that HR failed in the hiring process...well, if you think that in this case I sugggest that you've either been in the "sauce" or else you simply don't get it. I'll let it go at that.
:bonk:

What you said...

Compassion referred to in my post was that as a supervisor, I would be able to put myself in Joe's place and understand why he was not at top form I certainly hope that nobody in this forum would be so cold as to call someone an idiot because a family member died and he goofed some stuff up. You wouldn't really call this incompetence would you M?

If so, I'm glad I work where I do, because a year ago, this same scenario happened to me. My Mother passed away suddenly, I screwed up plenty, and my coworkers did collect a huge amount of money in twenty minutes to make sure I got back to the funeral with my children. (I had just found out that my husband was terminally ill, and we had racked up a huge amount of medical bills that were not totally covered by insurance) Thank God, or whomever you put your faith in that this was not viewed as my being incompetent.

Sorry all.

My response was to Energy's post, not Steel's.

quote

"For those who would advocate "idiot proofing" the process, I say that it is not very compassionate to instruct HR to amend that hiring process to make sure that that they don't hire idiots! "

Hope this puts my reply into context !

M Greenaway said:

Sorry all.

My response was to Energy's post, not Steel's.

quote

"For those who would advocate "idiot proofing" the process, I say that it is not very compassionate to instruct HR to amend that hiring process to make sure that that they don't hire idiots! "

Hope this puts my reply into context !

M,

It was sarcastic humor intending to show that not even HR can screen out all "idiots". Relax. Your boss made the right choice.:rolleyes:

In actuality, the prospective employee is dressed nice and everything appears to be in order. You make the decision to hire. At best, you covered all the bases and looked for those little things that suggest something may be "not quite right" with the applicant. Personally, I have not recommended hiring a lot of people. About 10 employees in my long working life. There were 2 that I would have liked to do over. After a few months, just long enough to make it past the "temporary" status, the real person begins to emerge. Errors, attitude and 180 deg turn from what I thought I saw during the interview. That's a 20% error factor for me! When I look around at work and see the performance of some hires, it is obvious that a few slipped through the cracks. Another factor to consider is the compensation issue. If you hire cheap, as a rule, you get what you deserve. My use of the word "idiot" was intended to show what I think of people who continue to operate outside the system because it's crock to them. They feel that they are just fine as they are and do not need to address competency and training and mistakes. "Hey, I'm only human."
Sorry for any misunderstanding regarding the use of the word "IDIOT"!!
:ko: :smokin:

Lack of compassion leads to fear in the workplace. I believe Deming and Juran have a lot to say about that topic.
And without compassion you cannot have success with principles 2 & 3.
I'm sure everyone has read it before, but, for a refresher see the detailed discussion of management and operator errors in Juran's QC handbook, chap. 17 & 18.

Martin,

Glad to see you weren't calling ole Joe an idiot. I understand where you were coming from better now. Peace.:truce:

energy said:
---------X-------------
Personally, I have not recommended hiring a lot of people. About 10 employees in my long working life. There were 2 that I would have liked to do over. After a few months, just long enough to make it past the "temporary" status, the real person begins to emerge. Errors, attitude and 180 deg turn from what I thought I saw during the interview. That's a 20% error factor for me!
---------------------

Only 20%? Energy, that's probably better than average. Well done.:D

/Claes

Agreed, Claes. In my current and former companies I was known as one who did longer, more thorough interviews (sometimes with tests) and background/reference checks than anyone else. I even sought input from the receptionist who greeted the interviewee and/or may have met the person first when they dropped-off their resume or application - I wanted to see how the candidate treated them and acted when only the receptionist was around. Still, I can only claim a 70-80% success rate as defined by "would I hire this person again, a year later, if I had it to do over again". As Energy, I have occasionally seen a transformation after a hire passed the probationary period. I doubt that "world class" in hiring success (as defined my way) is much better than 90% because we're dealing with humans who can be deceptive.

This whole tangent on hiring personnel makes me wonder...

How many people have competency tests or other type of screening devices they administer to perspective employees to "weed out" those individuals who might not be able to read, write or cypher good without taking off their shoes... (mathmatics... :biglaugh: ) ?

If you do have these tests, what kind of turnover do you have for employees with... oh, let's say... under one year? (Just pulling a number out of the air).

Just curious. :eek:

Cheers!!!

Mike

Most of the candidates I did testing on for a few years were technician-level folks with at least some college, tech school, or military school. It was amazing what I would find out, on occasion, in a short 10 question test covering the very basics of the applicant's (supposed) area of expertise (they were given calculators, scrap paper, a very fair amount of time - 3X what should be needed - and left alone to take the test)! However, eventually HR got to sniffing around and said that my tests might be someday construed as biased in some way against some minority group and I should not give a test if it has not been vetted by a professional testing organization as being unbiased. What crap that is, but I stopped. The test was just one tool out of many I used to select people -- another data point. I think it helped me and the company choose more wisely in some cases.

When the next company began giving "professionally done" tests for general knowledge they stopped after less than a year so I cannot comment on turnover then.

Mike S. said:

However, eventually HR got to sniffing around and said that my tests might be someday construed as biased in some way against some minority group and I should not give a test if it has not been vetted by a professional testing organization as being unbiased. What crap that is, but I stopped.
When the next company began giving "professionally done" tests for general knowledge they stopped after less than a year so I cannot comment on turnover then.

And you know perfectly well, why. Short of asking "Who was buried in Grant's tomb?", the results were the same. Sorry Folks, but men may have all been created equal, they just didn't stay that way! More do gooders dictates from those who have no concern for the organization's bottom line. Just as long as it isn't theirs. Wait, this isn't the political thread. Disregard all after "Sorry Folks....." :vfunny: :smokin:

But what about us ‘experts’? Is it possible for us to make mistakes? I know I made a mistake once. I only have 6 more years of child support left. :eek: (Yes, it was work related, but I shant go into details) But seriously, if I forget to pack my standard in my case when I go visit a client, is it my fault, or the system's fault? How can I error proof the 65 mile drive to ensure I don’t have any delays on the trip?

Easy answer, db. In your example, us "experts" are part of the "system" which is always at fault, so you are at fault in this case. And if the average "hourly production worker" Joe or Jane forgot to take the standard (let's say they were for some reason invited to visit the customer), it is still your and the system's fault. Got it?:vfunny: :rolleyes:

From the Deming Conference last weekend:

A presenter offered this explanation – only when the root cause is traceable to a Company Value that was willfully broken can the employee be at fault. These ‘company values’ are developed by everyone in the company, not just management. Everyone needs to operationalize the definitions so that all agree what is “is” and live by them as a culture.

All other failures are attributable to the System.

Regards,

Kevin

Kevin,

I don't get it (again). Unless it was a WILLFUL screw-up the system is always at fault?

So in our earlier example of a despondent Joe, whose relative died, the system was at fault?

If a truck driver momentarily was distracted by ____ (fill in the blank - a pretty girl walking down the street, sunlight in his eyes, the high-beams of an oncoming truck, the appearance of a ball bouncing into the street, a sudden change in the sound of his truck, etc. etc.) and has a wreck, it is the system's fault?

If a machinist, reading the blueprint for a part he is making, unknowingly transposes the numbers in the size callout (i.e. should be .5470" +/- .002" and he "thinks" .4570") and machines the only piece of stock available undersize, the system is at fault?

I have to disagree with this guy. (Or, maybe I'm just not smart enough to understand what this presenter was saying.):confused:

Kevin Mader said:

From the Deming Conference last weekend:

A presenter offered this explanation – only when the root cause is traceable to a Company Value that was willfully broken can the employee be at fault. These ‘company values’ are developed by everyone in the company, not just management. Everyone needs to operationalize the definitions so that all agree what is “is” and live by them as a culture.

All other failures are attributable to the System.

Regards,

Kevin

Just another opinion from another "expert" from on high, IMHO. If I forget to put water in the coffee pot, even with hands on training and being the only absent minded employee to do such a thing, our system is at fault? I didn't do it "willfully". C'mon Kev. Enlighten me. Something in this person's grand presentation made you post it. Do normal people make mistakes on purpose? That's Sabotage. This "Human Error" thing is way out of whack. I would have taken the Presentor to task with several examples of situations, including the one where the operator admits to making the mistake on something he/she does on a regular basis, where procedures and training work well for everybody else-most of the time. These people who concoct these deep interpretations give me case of the *as or gas! :vfunny: Being removed from the every day routine of manufacturing can give one a vision that mistakes are always the fault of the company and their System. Bull-cocky!:bonk: :ko: :smokin: :agree:

Gentlemen,

You presumed that I agreed with the statement. In actuality, I am still contemplating its worth. I merely put it out there for discussion.

Kevin

Okay Kev,

I thought of the possibility that you may be playing the Devil's advocate. But, I'm always a sucker for the right bait!!:rolleyes:

See Mike, two birds with one stoned!:vfunny:

Experience here has me thinking that there are those who agree with it. Look at the poll. :ko: :smokin:

I totally agree with the fella.

The analogy of Joe's cock up due to a relation dying is ridiculous. How on earth would you get to that conclusion from a proper 5 why process from the reported fault ??

Imagine Joe had incorrectly packed the wrong part. If we looked at the process and asked why, or even how this could happen we wouldnt jump to the conclusion that a relative of his had died. We may find however that he was packing two, or more, orders at the same time on his work bench and inadvertantly mixed the labels - as a result we might revise the process such that only one order or product is packed at one time.

Or maybe after some research we find that he had picked the wrong part from stores due to the similarity of part numbers, and the storage locations being adjacent - as such we might revise the stores put away process to ensure that products of similar part numbers are not held in adjacent locations.

Just a couple of examples where we could have stopped at operator error, but a little research shows the circumstances that created the possibility of operator error in the system.

Corrective Action is about creating robust systems to people variation, not blaming stupid operators and hoping that your criticism will stop it happening again - now that IS compassion !!

Martin,

If you go back to the original scenerio involving poor Joe, you will see that "Jo mispacks 20 of the next 100 cartons he is packing". Let's say that by "mispacks" it means he put the right parts in the carton, but forgot to wrap some of the parts in the required amount of bubble wrap, or maybe he writes the wrong part number on the part label, or forgets to use the anti-static bags on some of the parts. How do you practically and economically make that stuff foolproof? Remember, Joe has done this stuff practically forever with no errors, so it is not an obviously non-robust system.

How do you explain away the other examples I gave (the truck driver and the machinist) as always the fault of the system and create "foolproof" CA's by practical and economical means?

In your world, can any car wreck EVER be the fault of a driver? Please explain.

IMHO it is you who are oversimplifying the CA process by rubber-stamping every failure as a system failure. For what it is worth, it looks to me like the vast majority of the poll respondents do not agree with your analysis, either.

Nuthin personal.
:smokin:

M Greenaway said:

I totally agree with the fella.

Corrective Action is about creating robust systems to people variation, not blaming stupid operators and hoping that your criticism will stop it happening again - now that IS compassion !!

Personally, I was talking about after you have done an exhausting study that simply points to Operator Error. Nobody is advocating applying OE at first glimpse. In many instances, the system was adequate for years and all of a sudden it's not? And, I respectively add, your past posts regarding foregoing CA/PA on every single thing could come into play here. Let's not start the thread all,over again.

I disagree with the Fella!:frust: :ko: :smokin:

Energy

The decision when or when not to take CA is based on identifying causes as special or common, and relating these to process capability. Correctly identifying root cause is a related issue, but a slightly different kettle of fish.

I guess we will have to agree to dis-agree. I know I am probably in the minority, but in good company.......

M Greenaway said:

Energy

Correctly identifying root cause is a related issue, but a slightly different kettle of fish.



M.,

Maybe I'm experiencing a blockage in my information input system. I thought this discussion was about using Operator Error as an unacceptable Root Cause because it's supposed to be always the System's fault. Please enlighten me as to where I lost my way. I just hate wandering about in the dark :rolleyes:
:ko: :smokin:

Martin,

Do you consider being against the opinion of the guru Dr. Deming and 97% of the practicing quality professionals in the Cove as being "in good company"? One could take that as a veiled insult but I won't. :p

Please, who exactly is your "good company"?

Whoa....have to add my two cents here:

There is operator error, and I also believe that you could design a system to prevent operator errors once you have identified them. But is it worth the expense?

Economics will dictate how robust we design our processes and to what extent we will tolerate operator errors. When they do happen, and they will, then reaffirm the process' capability with the customers' expectations. If there is still alignment, then accept the error as the honest mistake it probably was and move on to more important issues.

Still believing in the innate goodiness of mankind..........

Slowpoke,

Sounds to me like you have your feet on the ground. Good post.

Martin,

By the way, Martin, if you want to continue to disagree that is certainly your right and I respect it. But please, if you believe in your position so strongly, explain to me how the scenerios that I brought up previously (page 3, next to last post) fit your explanation of a system failure. I really want to understand your viewpoint, even if I don't share it.

M Greenaway said:

I totally agree with the fella.

The analogy of Joe's cock up due to a relation dying is ridiculous. How on earth would you get to that conclusion from a proper 5 why process from the reported fault ??




Production manager, "Joe, it's good to see you back. We were all very sorry to hear of your loss, is there anything we can do for you?

Joe, "No, I'm doing OK, I'll sure miss that ol' geezer, he was my hero as a kid."

Production manager, "Yeah, that's a tough one, you make sure to let me know if you need another day, or something, OK?"

Joe, "sure thing, PM, I appreciate everything the company has done for me. And, by the way, I heard about the screw-ups with that packaging the day I left. I'm sure sorry about that. I know we had a perfect record, 10 years and no mis-packed boxes. I knew what I was supposed to do, I just kind of zoned out. Ya know? I couldn't believe it when I heard he died, there's no excuse other than I just wasn't thinking about my job."

PM, "It's alright, Joe, we know that you didn't mean to mess up, and your record is great. There was no harm done, everything was accepted, they were just concerned that we were cutting corners by not adding the amount of packing material they requested. It isn't going to cost us a thing now that they know what happened."

Joe, "Thanks, PM, I was real worried when I realized what I'd done, that's a big account and I'd hate to make 'em mad."

OK, so now tell me again why there had to be an in-depth investigation, 5Y or anything else? If you know what caused the problem, it is an isolated incident, the effect is minimal and the guy admits that it was a brain f@%t, what more do you want?

Call me lazy, but that would be good enough for me, as long as there are people involved in the process, there will be mistakes made. Computers don't program themselves, just look at Mickeysoft:biglaugh:

Mike

I actually voted in the 96% range, agreeing with Dr Deming, which is where my quip about good company was aimed. Reviewing the actual results of the poll however I am in fact in the majority.

So what are we arguing about ??

Enough anyway ;)

Martin,

Is it me, or are you being somewhat inconsistent, Martin? Your vote and your verbiage do not always match IMO.

Kevin said, “A presenter offered this explanation – only when the root cause is traceable to a Company Value that was willfully broken can the employee be at fault. These ‘company values’ are developed by everyone in the company, not just management. Everyone needs to operationalize the definitions so that all agree what is “is” and live by them as a culture. All other failures are attributable to the System.”

In response, you (Martin) said, “I totally agree with the fella.”

In another thread, you said, “The system is always to blame in one way or another. People make mistakes, and every problem could be traced to someone making a mistake, however it is the system that allows mistakes to happen. Or in certain cases prevents the processes functioning to required levels. The only possible exemption form this is if someone willfully neglects to do something, but even then it is part of our system to hire competent people, give them resources, motivate, etc. If you blame operator error I will guarantee that any action taken on the operator, as opposed to the system, will not result in any improvement of any kind.”

And, you said "And in my opinion the red bead experiment is analagous to any problem. Yes it is simplistic and obvious, but the message is that the problems lie in the system, not the operators"

Now, you say "I actually voted in the 96% range"

That is why I'm having trouble understanding your true position. But, lately I've been having trouble in this area (understanding what people mean), so maybe it is just me being dense again.
:truce:

Mike

The great thing about this forum is that we can discuss things and modify our opinions - and I am certainly open to that.

I think I have been by and large reasonably consistent, with some slight modification along the way. I voted the 96% range, and as one of my posts that you quoted shows that I feel the majority of problems are with the system, unless the operator is willfully neglegent. Now I said that prior to Kevins post about the speaker at his Deming conference, who stated the same opinion. I modified my statement to say that I was even unsure of the other 4% of willfull neglegence being the fault of the operator and not the system, saying that it is our system that hired them in the first place, trained them and motivates them - perhaps. Which kind of suggests a 100% fault with the system, this is where my thoughts are tending to lean, but to air on the side of caution, and knowing that an exception will always break the rule, I plump for 96%.

I think we need to concentrate on where or how the system failed in all incidences if we want to be able to change anything for the better. By shrugging our shoulders and putting it down to an operator error is in my opinion failing to recognise a shortfall in the system which may need plugging, if the incidences rise into our Pareto analysis for action.

So in the case of the employee whose relative died I would still put the fault down to where the system failed, but the occurence of one in ten years, if true, suggests that I need not take action on the system cause. If I concentrate on the system cause I may well find a trend developing in poor packing, last week it was Joe cos his uncle died, the week before it was Fred cos his hamster had a headache, the week before that it was Bill cos he was hungover, etc, etc, from which I may well see that my process is not robust enough to the vagueness of the mental state of my employees - or not as the case may be.

Okay, Martin, I think I'm understanding your position better now. Just one final question if you don't mind me asking. Considering automobile crashes/wrecks of all types, whether or not the driver is acting as an employee for a company or as a private citizen, do you still feel that "the system" is at fault 96%of the time, or 100% of the time, or "other" (please specify)? Just trying to understand...

Mike

The scenario you talk about is a bit of a stretch compared to the industrial situation we are talking about perhaps.

But you can see that highways designers do consider the 'system' i.e. road surface, junctions, surroundings, signpost, lamposts, crashbars, etc when they design new roads. They dont just shrug their shoulders and say that human error means they can do nothing about avoiding crashes. If that were the case there would be no such thing as crash barriers up the middle of our Motorways, etc.

I am sure when they analyse crash statistics they look at the 'system' that caused it, as mentioned above, and try to re-engineer it to avoid future similar problems.

Mike S. said:

-----X----Considering automobile crashes/wrecks of all types, whether or not the driver is acting as an employee for a company or as a private citizen, do you still feel that "the system" is at fault 96%of the time, or 100% of the time, or "other" (please specify)? Just trying to understand...

Hullo,

Hope you don't mind my dropping in on the conversation? :D I just couldn't resist it...

Anyway, examples:

From the very start we've been building roads where cars pass each other with scant feet between them at closing speeds up to well over 200 km/h.... ...and placed mere humans with all our faults in command of the vehicles... What kind of a system is that?

On the other hand we have drivers with road rage blazing from their eyes, practically running you off the road unless you get out of their way fast enough. What system could possibly cope with that? Maybe a system that won't allow them to drive?

/Claes

Claes

Again the scenario you describe could in some way (as you suggest) be avoided by the system, but again it is a very extreme case.

Its a bit like saying what if a madman runs into the factory and smashes all the days productioin with a sledgehammer. Well lets just live the fantasy for a moment that it did happen, you could change you 'system' to avoid it, but based on occurrence you would probably take no action.

So the wild scenarios painted to illustrate some of the points above serve only to illustrate the need to base corrective action on occurrence and severity of the incodent, rather than supporting any claim of operator error being a true, or useful root cause definition.

If madmen ran into your factory every day to smash up production you would take action on the system, i.e. some restricted access to the building, etc.

No worries,

Like I said, I just couldn't resist throwing those examples in..;)

/Claes

In the road example...

The system could be designed to prevent error. For example, we could have chosen a type of mass transit, with robotic operation, on guided tracks, etc. Given the absurdity of this as an option to individual freedom, the cost involved and benefits projected, we chose not to implement such a system. The result is a system that allows individual nonconformance.

That said, the rest of the discussion regarding how the road system works focuses on cost/benefit analysis. Automobiles could be designed to be safer - we balance the cost of these improvements with the cost of manufacture and benefits anticipated. For example, seat belt technology was available long before implementation - see the inclusion of seatbelts on the Tucker vehicle and how long the other automakers procrastinated before adopting this innovation.

The same goes for highway speeds, vehicular regulations and enforcement, etc. Where we see increased benefit offsetting the cost, we implement.

I guess my point is: any system could be made so foolproof the operator could not cause nonconformance. But we choose the level of "idiot-proofing" on the basis of implied or actual cost/benefit analysis. The system, or lack of same, is therefore at fault...

Ahhh, but remember the old saying, Bruce:

If you make it idiot-proof, someone will build a better idiot!;)

Has anyone defined the System yet? What is the scope of the System? What are the components?

Regards,

Kevin

Kevin Mader said:

Has anyone defined the System yet? What is the scope of the System? What are the components?

Regards,

Kevin

Oh c'mon, Kev. The system is anything else to blame, except me! Wasn't Joe, Mary or me. Pretty to hard to argue against that, as we see here. That friggin system! :bonk: :ko: :smokin:

Jim Wade said:

OK, I'll be neck-sticker-out on this one ...

The components of a system are:

- methods/processes/procedures...
- resources (materials, people, information. money...)
- tools/machines/technology...

If, as in this thread, we want to debate person vs system, then the system must, in that case, be all the other stuff except people.

Incoming!!!!!!!!!!!

rgds Jim

Jim,

I like the definition! People are resources and the system is responsible for maintaining the competency of this valuable resource. However, I know here we go again, sometimes there are unforeseen glitches in the system. Try as you may, they can't all be anticipated. Like an otherwise competent employee making a mistake. Like visiting your favorite place for relaxation in the Company and realizing, much too late, that the Toilet Paper Dispenser is empty and you have no neighbor to borrow from. Darn Purchasing. Darn Cleaning Personnel. Darn Borritto for breakfast. Blame the System. That's where the responsibility lays. It's very fashionable in certain circles and avoids the real reason. People make errors. :agree: :ko: :smokin:

IMO I think this is where we should try to get to - only system failures. As an operator if I follow my process/procedure to the letter and I still have nonconformities then the system failed me. However, all processes or procedures have to make certain assumptions - personnel are trained, have 2 eyes, can read, have more sense than the part they are making, in other words they have the skills to perform the procedure.

Randy Stewart said:

IMO I think this is where we should try to get to - only system failures.

Sure would be nice. But, this is today. Things happen due to occasional lapses in concentration in even the most competent of employees. System, shmystem. It's people. As someone posted earlier, you cannot error proof every single task one may be asked to perform.
We had a master plumber with 10-15 years experience performing a valve installation. It requires applying air pressure to close the butterfly valve to reduce the envelope for proper installation. Others have performed this operation for even longer with no mishaps. This particular day, the very competent person was pre-occupied with marital problems (only finding out later) and left half his little finger in the throat of the valve when he closed it. Literally left it there. Like, no longer has it. The System was not at fault and no amount of saying it was, makes it so.
The valves are spring opened to allow flow during an energy loss. (Air or electricity). They are sold in the open position by the thousands. Locating the air supply shut off far away from the point of this operation and maintaining an unobstructed view of pressure gages has served us well for many years. Why this individual decided to hold the valve in his hand and gaze at the clock during this hands off procedure is due to carelessness and not the system.
Nope, those who insist the system is always at fault are toying with semantics. Yes, people are part of the System. But, so are rejections, corrections, Corrective Actions, etc. Why, we even have systems within the System to address them. I will never attribute system malfunction to an obvious employee mistake.
If I'm ever told we didn't do enough to prevent employee errors, by somebody in Authority, I'll let you know. Good process assessment will take into account all reasonable risks and cause the process to be stable for NORMAL operations. Power to the System. I'm getting dizzy. :bonk::ko: :smokin:

Jim Wade said:

Well one thing's for sure, energy: no-one will ever accuse you of being a Deming-lemming! ;)

Just to make sure I understand where you're comimg from, is your view:

1 All problems are due to people error and never to the 'system'?

2 Most problems are down to people, fewer are attributable to the system?

3 Something else - please specify.

rgds Jim

Number 3, Jim.
Not excepting an identifiable operator error as a root cause and blaming the system is looking through ideological "blinders" ! And 1. & 2. of your understanding where I am "comimg" from is a good example.
:agree: :ko: :smokin:

Jim,

Thanks for sticking your neck out (whack!! just kidding):biglaugh:

Actually, I was wondering if folks consider components like the Environment, the Community, the Customer, the Supplier, etc.

In the two examples (Poor Joe and the Road Construction), are other elements in the System (larger than the one Jim described) at play? What consideration is given to these components when creating operational definitions, for example?

Energy a Deming-lemming?? Nah!! He is a free thinker piecing it all together. Like he said, only certain bait gets him to bite. But I'll land him one of these days(poor attempt at fishing humor)!;)

Regards,

Kevin

Would it help if we took the stance that either everything is operator/human error, or everything is system error.

As I have said before the system is in place because we are human, it is there to avoid human error - that is its purpose.

What I have seen with root causes named as operator error is that all we do is talk to the operator about the problem in the mistaken belief that by talking to them, bringing it to their attention, it will never happen again - or even reduce the likelihood.

Thinking in terms of the system being at fault is not a cop out, or idealogical, it is the only way to attempt to reduce instances of defects/problems.

Well I beleive the Mayan calendar which clearly states the world will end in December 2012.

If it doesn't, do we blame the humans (Mayans) or the (solar) system?

:bonk:

Dave

Very punny, Dave.:rolleyes: :bonk:

Jim Wade said:

Deming, as I understand it, would tell you that 85-95% of your problems are built in to your system by you and your management colleagues and that only 5-15% are due to 'special causes' - including your people screwing up.

rgds Jim

My posts have been directed at those who "never" accept operator error as the root cause. And, in this tight as*ed "Q" arena, there are many who would have you believe that they never make a mistake. Bullfritters! A dollar to a doughnut that they never reveal their mistakes, let alone blame the system. Why focus on their own mistakes? Because their mistakes are just not as important as the production worker. Egomania Reigns! Empty that Recycle Bin! :p :ko: :smokin:

All problems are due to people error and never to the 'system'?

Absolutely! This "system" thinking is only to cover up our mistakes. It actually proves that it is a fraud.

"It wasn't me...it was the system.

Why did the system fail?

Someone forgot about a variable.

Why did they forget?

The variable wasn't in the system.

Why wasn't it there?

Someone forgot to ad it.

Why did they forget?

The system failed to ensure it would be remembered.

Why did the system fail?

Someone forgot about a variable....."

System thinking either requires circular thinking above, or somewhere along the line we have to come to the point that someone goofed!

ALL SYSTEM FAILURE ANALYSIS WILL EVENTUALLY LEAD TO HUMAN FAILURE!

Now don't go misquoting Deming. My comments are just that if you dig deep enough, all system failures will result in someone failing. It is easy to blame a system, but why did the system fail? Without exception, if you follow to the root cause you will always find human error. Systems don't just happen, they are created. Any system failure means the creators did not build in enough, or proper fail-safes. System creators, being human, then are the root cause.

My statement stands, and I challenge anyone to prove that a system can fail without human failure.

Up to the challenge?

Deming used this to explain the interactions and cumulative effects of the System and the individuals working in it:

X – the contribution of the worker
XY – the contribution of the System

X + XY = the output

Note that Deming did not eliminate the human element from the contribution of the System. Are we trying to solve this equation?

Regards,

Kevin

I'm not trying to solve the equation, or contradict Deming. But, Deming's formula illustrates my point:

“X – the contribution of the worker
XY – the contribution of the System”

Notice that the system “XY” contains the “X” from the worker. My point is without the individual, the system could neither be created nor operated. Therefore, all system failures are failures of the system creator (worker).

Right on Dave.

Which takes me back to my modified opinion (in my last post I think) that you either take the stance that all failures are system failures, or all failures are human failures.

I would recommend concentration on the system, as that is all you can probably do anything about.

Okay, it is a new day, and the drugs from yesterday have worn off. Back to reality.

Martin said:

I would recommend concentration on the system, as that is all you can probably do anything about.

You are correct Martin. Although all system failures can be traced back to human error, we should concentrate on our efforts on correcting those things that we can correct. Once the system is in place, it would probably not be a good use of resources to trace back to find “who” made the initial error that allowed the system to fail.

Error-proof the system and move on.

John made a mistake. It doesn't say that there were inadequacies in the system. You "blame the system" proponents say that. The system has been in place and has been adequate for years. John just ****ed up. Pure and simple! This is like a merry-go-round.:biglaugh: :ko: :smokin:

Logic dictates that mistake proofing can be taken to an extreme where monkeys can do the task without the risk of failure. At what point can we as professionals make a sound business decision that our system is adequate "as is" without throwing more and more money into the "excellence pot"?

It would seem to me that regardless what percentage is attributable to human or system, the overriding determinination has to be common sense. If I reach a system state which yields a high sigma value and a human error causes a momentary lapse, would the prudent course be to spend time, money and resources on developing a CA for the system? Chances are, and historically supported by empirical data, that the error is unlikely to repeat. Couldn't the CA in such a case be directed to the human element?

I am certainly not saying you needn't look for the "why". If at all possible it should be found and analyzed. If practical, a CA could be developed for the system error, but if not practical the human error should receive the CA.

I agree that you should give the greatest attention to the areas you can do something about, but don't you believe I can't do something about the humans who work for us.

Just my opinion on the subject.

Dave

Jim Wade said:

If we took a 'blame-the-person' approach in the case I mentioned, we MIGHT conclude that "the product has a problem, therefore manufacturing, or the shippers or whatever are to blame". By thinking of the system and using root cause analysis, we MIGHT get closer to the root by figuring out that it's really a design problem or, say, a problem with prospect qualification. So at least we get to the person who actually screwed up.

rgds Jim

So this is where we differ in our approach. When we have identified who, always the easiest thing to do, we look at the procedure to see if the "process" was adequately defined. After all, the "process" has been identified by a group of people, approved and released for use. The individual is not approached, at least by me, until this step has been completed. Almost invariably, the worker did not follow the procedure. Took a shortcut, decided to take a break and lost their train of thought or were just too busy to do it right. Not ruling out training, a "system" thing, we see that the employee has been trained and has sucessfully completed this tasks for weeks, if not months, on end. You may say that being too busy, their excuse, it may be a resource issue. Using lack of training or resources as a root cause for this veteran employee isn't going to be accepted by Management and would require them to negate any CA/PA Action. Quite simply, ignore it or refute it. Either way, we will not arrive at timely or effective CA/PA. Classifying it as "employee error with the unlikely to happen again" or "isolated incident" is my determination in dealing with this reported event. We encourage Problem Reporting and look at them all. If we were to ignore them, based on severity as has been suggested $$$, discourage problem reporting because no action was taken. It's a headache for me, but one I can live with.
To be completely fair, there have been times when the "process" as defined contained some ambiguities that cause confusion and subsequent "system", if you like, failure. These are rectified immediately through the revision process and are my favorite CA/PA. Black and White. No gray areas.
Without classifying nonconformances either "all people" or "all System" problems, not necessary IMO, we should be allowed to use "Employee Error" when it is determined that it was just that! No amount of coloring can make it a "System" problem. To attempt to do that to satisfy some egghead is not honest.
We all make mistakes and the system is not always to blame. Feck? :vfunny: :ko: :smokin:

The reason I posted Dr. Deming’s equation was to illustrate that there is significant interaction between the system and the people in it. The two are virtually inseparable. The equation is also unsolvable (without a simultaneous equation).

My concern is with blaming folks where it is an XY situation. I’m not really sure that we often possess the proper perspective where we can allocate such blame. This is why I pressed on what makes up a System. If we overlook the influence of system components that we don’t acknowledge or aren’t aware of, it is easy to conclude that something else is to blame. Often, it means blaming the fallible human. Let’s face it: if we didn’t live in a time where the Management Philosophy wasn’t fixed on laying blame or ruling by fear, more folks would be like energy – willing to accept it.

The aim should be focused on improving the System. Measurement systems should target System metrics – not an Individual’s performance measures. As Dr. Kano stated, leverage your efforts (inch wide, mile deep thinking vs. mile wide, inch deep thinking). Placing the focus on the System, real improvements can be realized. By focusing on just improving individuals, we loose the forest in the trees and ultimately end up with the same level of quality, or worse.

Now, returning to the willful vs. accidental errors, is there truly a distinction? Was Poor Joe influenced by another System Component that we overlooked? Or was it within himself to avoid the error, and if so, why didn’t he?

Regards,

Kevin

p.s. if your system required the input from the environment, say wind for a windmill used to pump water, if the wind doesn't blow, was this caused by human error? Or did the guy just build it in the wrong spot?

Kevin Mader said:

p.s. if your system required the input from the environment, say wind for a windmill used to pump water, if the wind doesn't blow, was this caused by human error? Or did the guy just build it in the wrong spot?

Silly Kevin, haven't you ever heard of a weather system?
:bonk: :vfunny: :rolleyes:

Okay - let me propose this logic flow:

1) All humans are fallible.
2) Systems are designed by humans.
3) Systems are fallible.

(We could discuss the proposal that, theologically, there was one infallible human - but I'm not going there...)

In Deming's equation, the person cannot be separated from the system - therefore, you cannot blame the person as a root cause of a non-conformance. However, all systems are inherently flawed because they are designed by humans --

So, my root cause is always human error.

My corrective action - remove all humans.

Let's see how much work gets done now... :smokin:

Aren't these exercises fun?

:biglaugh:

Kevin Mader said:

1. Often, it means blaming the fallible human. Let’s face it: if we didn’t live in a time where the Management Philosophy wasn’t fixed on laying blame or ruling by fear, more folks would be like energy – willing to accept it.

2. By focusing on just improving individuals, we loose the forest in the trees and ultimately end up with the same level of quality, or worse.

3. Was Poor Joe influenced by another System Component that we overlooked? Or was it within himself to avoid the error, and if so, why didn’t he?

Regards,

Kevin

4.Or did the guy just build it in the wrong spot?

1. Blame the individual if he/she is at fault. You are assuming that there is a problem with the system. I'm telling you that is not always the case. It also has nothing to do with acceptance of a system that focuses (fear) blame on the employee for everything. Is that how it is in your company? I can assure you that it has been tried here and elsewhere and the employee has been deemed "innocent" due to no defined procedure and acceptance criteria, several times. And, you can't frighten me!
2. If the employee needs counseling, so be it. This forest and the trees thing is not applicable. Actually, I'm pretty good at identifying the problem trees in our forest. Some need pruning and some just have to be cut down so that the other trees might grow.

3. Joe may have been under the influence, but it wasn't a system component. He didn't avoid the error because he is human and no cost effective or amount of error proofing could help him. The only error proofing that I could think of, in some cases, is to have someone else do his/her job.

4. The employee built the windmill against the face of a granite cliff. But, someone gave him the plans, right? The system failed because they allowed an incompetent engineer to draw up the plans? More like, the wrong Engineer. :bonk: :ko: :smokin:

I think therefore I have operator error?

I agree that every root cause could (or possibly even should)eventually end in operator error if the journey to that conclusion reveals truths that will aid in a fair and proper action. But should it always be called that?

Your arguments are all compelling. But I find myself drawn into the discussion (and at much risk) because while the debate may not hinge on this factor, we have to remember that the "operator" as a system variable, is also a person, and as such, will react to stimulas accordingly. (aka Morale)

(Maybe it's there parents fault.) Mr. Johnson, my names Steve MacDonald, and I'd like to audit your relationship to your daughter. She's having problems at work.

That system variable (I cringe to say this: feelings) should have relevance in this analysis in so far as realizing what it would be like to work in that environment, and its global impact on the company, and I would hazard, the entire oject of a quality system.

If we (I) hope to seek approval, assistance, (God forbid--an actual embracing of any quality system by anyone) in an environment where everything, regardless of the breadth or depth of the evaluation, results in some operator being fingered for everything that goes wrong we must certainly be mad.

What are the side affects to that kind of company (quality) culture? Operator error "implies" incompetance. It may be true but is it wise (tactful) to proceed in such a manner, or to espouse a system with such an emphasis, management sanctioned or not? Would you want to work there? Would you want your friends to work there? Your enemies?

I'm still new to this, and you'll proablt beat my a** for adding my two cents but there it is. (Ka-ching!)

Steve (Waiting patiently for his beating)

Steve,

I have asserted all along that someone has to screw up to bring about the investigation of what went wrong and it was reported. I also said that the system is agressively assessed, first. The employee's mistake is always viewed as a system weakness. Only having determining that the system has worked for everyone else and is not in need of modification, does it make sense to call it what it is. Human error. It happens. To shade it as something else, out of compassion for the worker bee, is dishonest and serves no purpose except to avoid the real reason. If I accepted the idea that all errors I commit are due to system failure, I'm ducking responsibility for my feck ups! That's English. :vfunny: "I made the mistake because I'm so busy due to a lack of sufficient resources which would allow me to work at my own comfortable pace." Or, "Maybe I need some training in Time Management". These are stretches and amount to excuses for not accepting what is common to all of use (Those who admit it). People make errors and sometimes they are huge.
One more time, my issue is with those that never accept human error as a possibility and refuse to call it that for root cause. It does become an "incompetency" issue if the mistakes are made repeatedly, by only the same person. For the occasional slip up, employee error, IMO is acceptable root cause.
Example: We recently had an error that resulted in a Sales Person
released an incorrect order. Subsequent discussions with the Customer revealed the miscommunication. The person said, "I have a thousand excuses, but none of them are good enough. I just fecked up". What do you do? He cut 15 orders that day, according to the established system, and botched one.
Somehow this thread has turned into "abusing" the poor employee without looking at the system. Not so. It's just candy coating previous posts that insist the system is at fault thereby poo pooing "Operator/employee error" as an accepted root cause.

I, for one, enjoy your posts. Never be worried about getting beat up. Contrary to some beliefs, nobody is smarter than the next one here in the Cove. It's just a matter of cutting through the smoke and mirrors! Abbracadabbra?. Presto! I'm gone.:agree: :smokin:

Mike,

Weather systems...now there is a confusing system to dissect!!

energy,

I'm not sure my comment on fear came out the way I meant to state it. Where fear is prevalent, folks are often overly defensive, even when they don't need to be. My guess, based on your comments in this thread, is that you will take the blame easier than most. My feeling is that your comfort level (pain threshold?) is higher than most.

4.) I was thinking about a windmill placed in an open plain. It sits next to a small home and was erected by the homeowner, a farmer noless.


Kev

My boss says I am the best example of the Peter Principle that he has ever witnessed. Did he make an error, or am I incompetent?

That depends on whether or not you have stopped climbing.

He may be meaning you are good at whatever you are doing and still haven't risen to the top.

Remember it is the "Peter Practice" that elevates you past the level of your incompetence then demotes you. As long as you are still working on the "Principle" part, I would say you have nothing to worry about.

Who knows, it may be your boss who is about to experience the "Practice" end.

Thanks for the laugh. Have a nice holiday.

Dave

The Peter Principle was first introduced by L. Peter in a humoristic book (of the same title) describing the pitfalls of bureaucratic organization. The original principle states that in a hierarchically structured administration, people tend to be promoted up to their "level of incompetence". The principle is based on the observation that in such an organization new employees typically start in the lower ranks, but when they prove to be competent in the task to which they are assigned, they get promoted to a higher rank. This process of climbing up the hierarchical ladder can go on indefinitely, until the employee reaches a position where he or she is no longer competent. At that moment the process typically stops, since the established rules of bureacracies make that it is very difficult to "demote" someone to a lower rank, even if that person would be much better fitted and more happy in that lower position. The net result is that most of the higher levels of a bureaucracy will be filled by incompetent people, who got there because they were quite good at doing a different (and usually, but not always, easier) task than the one they are expected to do.

db,

Sounds like he is saying that you are "maxed out". As for being demoted, this says you're all set. You have achieved the highest level of the bureacracy...but not to worry. Your boss is at the pinnacle, which makes him the Peter Principle Peter, so there's still room for you to climb to another level of incompetence. :vfunny: Have a happy.

:ko: :smokin:

Energy,

What happened to the OLD you? I miss that beard and corn pipe!

It has taken me a couple of days to wade through this thread and I decided to vote for choice #2 - system is at fault almost always. I work for a service organization where automating much of the work is not feasible. We (my employer and the customer) trust competent employees to carry out their assigned tasks as they have been trained.

Jaime

Most of our defects result from system.
So we should improve step by step

Okay - let me propose this logic flow:

1) All humans are fallible.
2) Systems are designed by humans.
3) Systems are fallible.

(We could discuss the proposal that, theologically, there was one infallible human - but I'm not going there...)

In Deming's equation, the person cannot be separated from the system - therefore, you cannot blame the person as a root cause of a non-conformance. However, all systems are inherently flawed because they are designed by humans --

So, my root cause is always human error.

My corrective action - remove all humans.

Let's see how much work gets done now... :smokin:

Aren't these exercises fun?

:biglaugh:

No human; no system.
No system; no product~
thus no problems

Unless you like food, shelter or clothing.

After more than 25 years in Quality, I see the same response to corrective actions, over and over. Operator error! In most cases, the supplier forgets that nonconformance is relative to two actions. One is the failure by the operation and the second is the escape at in-process or final inspection. This truly is systemic in its roots as these escapes should not exist. As it is difficult to weed out all errors and operators will make mistakes, sytems can always be improved!

dear Mike.
it is system inadequacy that leads to nonconformance or defect. with all the due respect to Guru Demming,i woild like to submit the following.
what is the purpose of establishing system?what all it is supposed to address.?what will testify that quality plans in the system are effective.?what do we ask the work team to follow? answer is obvious-it is system and guidelines,instructions,plans for prevention therein.-then why to dilute the issue to pull others at all.
Guru wanted to keep people in focus then -but in the fast world, one must catch bull by horn and attempt to ratify the system unhesitantingly because men can always say -we were not told about? care for your guidelines first.....hope you agree.
regards.
kumar.

Don't blame the operator. Just find out why interpretations or handling went wrong. In most of the cases it is psychologically defined. The 80/20 rule counts (80% operator!)

Don't blame the operator. Just find out why interpretations or handling went wrong. In most of the cases it is psychologically defined. The 80/20 rule counts (80% operator!)

Jack,

What 80/20 rule are you referring to? Source?

Stijloor.

Don't blame the operator. Just find out why interpretations or handling went wrong. In most of the cases it is psychologically defined. The 80/20 rule counts (80% operator!)What? Please give us some details about this.

:) Hi All,

I can't helped it to share...:tg: I voted for 96%... System/s built by
expert/s... but we cannot for anything in the world, get rid of this "employee error" (...i supposed... it could have been termed "Human error"). Employee is just one composition of the system.
I hope I didn't mixed up my word's...if so... please forgive me! Since forum is open for opinion...i'd like to make mine... :biglaugh: Procedures (sufficient and effective) were defined in the system...if people violated them intentionally or unintentionally:bonk:, doesn't it always unticipated by the system? why coined words such as corrective? preventive? and contingency/ies? aren't they for unticipated returns/NC? I think what we have here is how effectively we utilizes our RCS?
:2cents: Don't be harsh on your comments later... (just hoping!)

Newborn of "Q"
:magic:

:topic:b Sorry guys for too much smilies!!! I just found them cute to use!!!

Regards to All and ADVANCE MERRY CHRISTMAS TO ALL

:lol: