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

[Mike S.]

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?

[Kevin Mader]

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

[Mike S.]

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.)

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! 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!

[Kevin Mader]

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!!

See Mike, two birds with one stoned!

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

[M Greenaway]

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 !!

[Mike S.]

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.