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

[M Greenaway]

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.

[M Greenaway]

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

[D.Scott]

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



Dave

[Mike S.]

Very punny, Dave.

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!

[db]

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!

[db]

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?

[Kevin Mader]

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