Helmut Jilling
Auditor / Consultant
I have a case where we have molded well over a million parts with zero defects for over six months. Several defective parts were found at our customer and we have determined that the reason the parts escaped was that a trained operator, who has done the job correctly for months, failed to scrap the required number of start up shots were the defect - short shots occurs.
He admits he did not follow procedure.
The occurrence of shorts at a start up cannot be eliminated, it is essential that parts not be saved until start up parts are purged.
IS the root cause operator error?
If it is not, how do you mistake proof this type of situation?
Wouldn't "a trained operator, who has done the job correctly for months, failed to scrap the required number of start up shots were the defect..." be a more useful root cause than simply "operator error?"
Admitably, it begs the question of "why," but it is a more useful statement than "operator error."