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

[AndyN]

The response we got when asking what happened was "I don't know, I f-ed up." It wasn't the first mistake the shipping clerk made, but it was the biggest. The higher ups decided to find a new shipping clerk.

Oh dear. Throw the hapless employee under the bus...

 

[CCaantley]

Oh dear. Throw the hapless employee under the bus...

I don't disagree. My bosses tend to blame employees first and foremost.

PM - "Why did you let that drill break in the CNC?"

Operator - "The CNC head just dropped! (Counterweight chain broke)"

PM - "So why didn't you stop it?"

 

[Ninja]

PM - "Why did you let that drill break in the CNC?"

Operator - "The CNC head just dropped! (Counterweight chain broke)"

PM - "So why didn't you stop it?"

Me: What did the drill cost? What estimated cost would PM or periodic replacement of the chain cost? When the head dropped, was it a safety threat to the employee? Did it risk significant damage to the machine? What other parts of the machine should also be considered for review/service/replace and how often and what cost?

 

[CCaantley]

Me: What did the drill cost? What estimated cost would PM or periodic replacement of the chain cost? When the head dropped, was it a safety threat to the employee? Did it risk significant damage to the machine? What other parts of the machine should also be considered for review/service/replace and how often and what cost?

Exactly.

 

[Sidney Vianna]

The response we got when asking what happened was "I don't know, I f-ed up." It wasn't the first mistake the shipping clerk made, but it was the biggest. The higher ups decided to find a new shipping clerk.

Obviously, I have no idea of what the true root cause of this wrong shipment is, but in the past, I have become aware of a few similar cases which the root cause investigation led to the (surprising?) fact that people doing menial jobs were totally illiterate and hid that from the employer for ages. Some, even worse, were illiterate and had terrible vision, so, even pictorial aids were useless to assist them with their work.

So, in that case, the system fault was failure to screen illiterate candidates and candidates with vision impairments during the hiring process.

 

[AndyN]

Excellent point, Sidney.

 

[Jim Wynne]

We need to think about what's meant by "The system is at fault." Although it seems obvious, it's not so simple. There are times when the system is indeed at fault, but changing it isn't economically feasible. If the failure level is very low and the impact of failure is negligible, it might make no sense at all to change anything. This won't prevent benighted customers from asking for corrective action, of course. On the other hand, it's possible to guard against human error to the extent that it's economically responsible to do so, but human error will still occur. In any system where human influence is necessary, human error is inevitable. It's all about deciding when it's economically responsible to do something about it.

 

[AndyN]

It also occurs to me, triggered by Jim's post that problems which get to a customer aren't always as bad as they might seem. It can be the case that the manner in which an organization responds to their customers when things go awry is a huge confidence builder - they now know that if/when something doesn't go to plan, you are responsive to their needs. It helps build relationships, which is often overlooked.

 

[John Broomfield]

It also occurs to me, triggered by Jim's post that problems which get to a customer aren't always as bad as they might seem. It can be the case that the manner in which an organization responds to their customers when things go awry is a huge confidence builder - they now know that if/when something doesn't go to plan, you are responsive to their needs. It helps build relationships, which is often overlooked.

Andy,

Excellent point.

I absolutely agree with the wisdom of managing the relationship with customers carefully and closely through good times and well before bad times.

Managing the fulfillment of customer needs and requirements is a vital process. It may usefully refer to or include protecting the customer’s intellectual property when working as a contract manufacturer.

BTW, needs may be seen as undefined requirements.

John

 

[CCaantley]

Obviously, I have no idea of what the true root cause of this wrong shipment is, but in the past, I have become aware of a few similar cases which the root cause investigation led to the (surprising?) fact that people doing menial jobs were totally illiterate and hid that from the employer for ages. Some, even worse, were illiterate and had terrible vision, so, even pictorial aids were useless to assist them with their work.

So, in that case, the system fault was failure to screen illiterate candidates and candidates with vision impairments during the hiring process.

I really hadn't thought of that.

It also occurs to me, triggered by Jim's post that problems which get to a customer aren't always as bad as they might seem. It can be the case that the manner in which an organization responds to their customers when things go awry is a huge confidence builder - they now know that if/when something doesn't go to plan, you are responsive to their needs. It helps build relationships, which is often overlooked.

It was a quick fix to get our customer the correct parts, and they weren't overly upset about it. It just hurt our external PPM a whole lot.